Professional Documents
Culture Documents
Ten patients are expected to arrive during the hour. This is the
arrival rate.
The formulas use the following symbols:
l = arrival rate per hour (ic)
m = service rate per hour (i,)
1. Average time a patient waits:
,, achi evi ng s ervi ce excel l ence
Fotter/book 8/12/02 3:47 PM Page 334
The Hypothetical Laboratory has a simple waiting room and one
technician. Ben Blake, the manager, has been observing the wait at the
laboratory for several weeks. Not wanting patients to wait too long, but
hesitant to incur the cost of hiring another technician, he wishes to
calculate the average wait for his patients over a one-hour period. He also
wants to know how much idle time the single technician will have
during that hour. If the technician has substantial idle time, Mr. Blake
would like for her to perform some routine tasks, such as fill out patient
records and consult by phone with other technicians. He has compiled
the following information for this one-hour period. For this example, we
ignore variability and use averages to describe both arrival and service
rates for the lab's patients.
The average time it takes to treat a patient is four minutes; the techni-
cian can treat about i, patients per hour. This is the service rate-the
units of service provider capacity per time period.
Wq = l/m(l-m) Wq = ic/i,(i,-ic) Wq = .i,, hours or minutes
Wq means waiting time before being served. This calculation tells
(Continued)
SIDEBAR B: THE MATHEMATICS OF WAITING LINES
Chapter 12: Waiting for Healthcare Service 321
line is unique and they need assistance so badly, the help center might be able to
let the phone queues grow without much adjustment. The essential feature of the
calculation is to determine the point beyond which the length of the wait affects
the quality of the client experience beyond the level acceptable to the client and
the organization.
Once a decision has been made about capacity and demand balance, the organi-
zation has to plan for accommodating the inevitable waiting lines that uneven de-
mand patterns create. Here the challenge is to manage the wait in such a way that
Mr. Blake that the average wait for a patient is minutes. If that
wait time is unacceptable to him, he may have to add another
technician.
2. Average time a patient spends in the system:
T
s
= i/m-l
Ts
= i/i,-ic
Ts
= .: hours or i: minutes
This equation tells Mr. Blake that the average patient spends i: min-
utes in the system, including both waiting time and service time.
3. Average number of patients waiting:
L
q
= l:/m(m-l)
Lq
= ic:/i,(i,-ic)
Lq
= i.,, patients
L
q
means the average length of the queue, in number of patients.
Knowing that only i.,, patients are waiting at any one time, on
average, reveals to Mr. Blake that the space available in the wait-
ing area is sufficient.
4. Percentage of time the technician is busy:
b = l/m b = ic/i, b = o;%
The laboratory has one or more patients in it, either waiting or
being served, o; percent of the time, or about c minutes out of
every hour, on average.
5. Probability that there are no patients in the laboratory at any given
time:
p = i - (l/m) p = i - (ic/i,) p = ,,%
This is obviously the inverse of the previous formula. If the wait-
plus-treatment system has someone in it about c minutes out of
each hour, it is empty for the other :c minutes. Mr. Blake can use
this information to assign other tasks to the laboratory technician.
NOTES
1. Sherman, S. G. 1999. Total Customer Satisfaction: A Comprehensive Approach for
Health Care Providers, pp. 2627. San Francisco: Jossey-Bass.
2. Press Ganey Associates news release, January 10, 1997.
3. Press Ganey Associates, National Priority ListMedical Practices, March/April 1997.
4. Adapted from J. L. Heskett, W. E. Sasser, Jr., and C. W. L. Hart. 1990. Service Break-
throughs: Changing the Rules of the Game, pp. 13841. New York: The Free Press.
5. Cited in J. B. Jun, S. H. Jacobson, and J. R. Swisher. 1999. Application of
wai t i ng f or heal t hcar e servi ce ,,,
Fotter/book 8/12/02 3:47 PM Page 335
SIDEBAR B (continued)
322 Achieving Service Excellence
the customer is satised with it. Two major dimensions are involved. The rst is the
way the waiting feels to the customer. The second is how to minimize the negative
effects of the wait by managing the value of the experience to the customer. The
organization wants each customer to conclude that the experience made the wait
worthwhile.
A growing number of programs are helping doctors redesign their ofces by
xing problems that have long frustrated patients, such as week-long delays to get
appointments, hours spent in the waiting room on appointment days, too-brief
visits with the doctor, and the near impossibility of getting the physician on the
phone (Landro 2006b).
Programs that help doctors in solo and small group practices to work more
efciently heed lessons from other industries (Landro 2006b). One approach
relies on calculations used by airlines, hotels, and restaurants to predict demand.
The idea is that through better use of demand and capacity management strate-
gies doctors can cut patient waits in much the same way restaurants seat din-
ers and turn over tables efciently. Other approaches involve relatively simple
changes such as leaving afternoon appointments open for urgent visits, having
patients ll out paperwork ahead of time online, or providing follow-up care
through a phone call or an e-mail rather than taking up valuable ofce time.
Kaiser Permanente has launched a program to help the 12,000 doctors who con-
tract with its health plan to increase their efciency by using a new electronic
medical records system.
Weiss (2003) recommends the following practices for wait management:
Do the math to make sure the schedule is not too tightly packed.
Keep things moving during the day by having the right staff in the right
place at the right time, appointing a patient-ow coordinator to keep things
moving, not trying to do it all, setting aside time for returning phone
calls and doing administrative tasks, allowing after-hours visits, and using
modern technology.
Provide continual communication to patients while they wait.
Make sure the patient is provided with a variety of waiting room diversions,
or perhaps include pagers as some restaurants provide so that the patient can
leave the ofce for a while.
In many hospitals, ED patients are now able to check themselves in at computer
kiosks (Stengle 2008). For instance, Parkland Memorial Hospital in Dallas, Texas,
has three self-service computer kiosks, similar to those used by airport passengers
and hotel guests. Patients spend about eight minutes at the kiosks using touch
Chapter 12: Waiting for Healthcare Service 323
screens to enter their name, age, and other personal information and the ailments
they would like to see addressed. A nurse monitors the screen to assess patient
information, and those with chest pains, stroke symptoms, and other worrisome
complaints take priority. The result is a shorter ED wait at Parkland.
Often, family members are left in waiting rooms with little or no information
about the condition of their hospitalized loved ones. Creighton University Medi-
cal Center in Omaha, Nebraska, has addressed this problem by posting up-to-
date patient information on an electronic screen in the waiting room. To protect
patient identity, families are given a case number that represents their loved ones.
(OConnor 2007). In some hospitals, a color-coded system is used. Other hospitals
have pagers that alert family members that they should go to the information desk.
Such processes try to give family members information in real time.
THE PERCEPTI ON OF THE WAI T
Understanding what makes time y or drag while a person is waiting is a funda-
mental concern in improving the quality of the patient wait. The research on the
perception of waits has long supported the importance of managing this (DeMan
et al. 2005; McKim et al. 2007). Mowen, Licata, and McPhail (1993), for exam-
ple, studied the perception of waits in an ED and found that patients who received
time estimates were more satised than those who did not. Healthcare managers
must remember that everyone is different, that individual differences will inuence
how people feel about waiting in line, and that how people feel about the wait is at
least as important as how long the wait actually is. Following are factors that inu-
ence customers perceptions of a wait.
Occupied Time
As noted earlier, most line waits can be made to seem more enjoyable and less
lengthy if people waiting can be distracted or diverted in some way. Many clinics
and physician ofces have gone beyond the traditional magazine rack by offering
interactive video devices that help patients pass the time productively by learning
something about their health. A cancer specialist might offer an interactive video
that answers typical questions asked by new patients, or a dentist might feature
a video describing a procedure to whiten teeth. A childrens practice might offer
toys in a play area, and a physicians waiting room might have a television showing
CNN.
324 Achieving Service Excellence
The Walt Disney Company is the master of managing time waits by providing
diversion to its waiting guests. If the line for a particular attraction has become
extraordinarily long, a strolling band, acrobats, or some other distraction is sent to
entertain and occupy the guests. Although bands and acrobats might be inappro-
priate in a healthcare setting, pleasant diversions or distractions appropriate to the
situation can be provided for customers.
Time Spent Waiting for a Service Versus Time Spent
Receiving the Service
In many ofces, before patients are examined by the doctor, they are interviewed
by a nurse who listens to the medical complaint, gathers vital signs, and generally
obtains information. By the time patients are actually seen by the doctor, they have
already had considerable contact with a medical person, so the wait to see the doc-
tor does not feel so long.
Another way to spend the wait time is to teach patients in line what they are
supposed to do once they reach the treatment area. The education provided during
the wait time can improve or enhance the service experience and, in that way, ac-
tually becomes part of the experience. Videos in an orthodontists ofce can teach
kids how to insert and remove their retainers before they actually get them. The
orthodontist does not have to spend so much time teaching, and patients are en-
gaged before being tted for the device. Some organizations use a similar technique
while placing callers on hold. Callers listen to a range of options in the phone
menu, which helps them make the right choice. They may also be presented with
recorded instructional material so they may be better informed when they talk
to a real person. Most medical ofces require patients to ll out lengthy medical
history forms. These forms provide useful information, but they also give patients
something to do, which reduces how long the wait feels.
Anxious Waits
To patients who are apprehensive about what will happen to them during an
upcoming operation or about the results of a diagnostic procedure, the wait will
seem endless. Communication geared to reducing anxiety during such waits is
highly desirable. For most people, waiting to be discharged to go home is one
of the longest waits they face. They are so anxious to leave that any time spent
waiting is too long.
Chapter 12: Waiting for Healthcare Service 325
Uncertain Lengths of Wait
Providing a time estimate can help those waiting because they can see the end in
sight. The wait before a scheduled appointment is bearable because the patient
knows how long the wait will be, but once the appointment time is reached, in the
patients mind it is time to be served, and any time spent waiting after that will feel
longer. One orthopedic hospital discovered that by having the nursing staff in the
preoperative areas periodically check back with patients and update them on what
was happening, patient satisfaction was signicantly improved.
Unexplained Waits
When a patient does not know what is holding up the line or causing the delay,
the wait feels longer. Effective managers keep people who are waiting informed, or
they provide visual cues that explain the wait. For example, a longer-than-expected
wait in a doctors waiting room can be improved by explaining to those waiting
that the doctors schedule was interrupted by a serious emergency. On the other
hand, effective managers of queues will ensure that unoccupied laboratory person-
nel or empty treatment rooms are kept out of the sight of waiting patients so that
managers do not have to explain why their personnel are not serving patients or
why their treatment rooms have no one in them while the waiting room is full.
Unfair Waits
If customers think the queue discipline is being consistently followed and fairly
used, then the wait seems shorter than when they think people are being served
out of sequence. Good organizations recognize this truth and manage their lines
accordingly. At times, patients who are very sick or in some other special category
require the line discipline to be broken. These patients can perhaps be brought in
through another entrance so those waiting do not notice that the discipline has
been interrupted. For example, the ambulance entrance to the ED is usually some
distance from the walk-in entrance. This separation allows emergency patients to
be served rst and provides easy access for ambulances. Organizations that for
one reason or another need to break the queue discipline must nd some way to
communicate a reason for the apparent unfairness that patients will accept, such
as Heart attack case coming through! or Abdominal gunshot wound! People
generally defer their own needs to accommodate other peoples more immediate
326 Achieving Service Excellence
needs as long as they know why. For example, passengers needing assistance board
planes rst and nobody minds, drivers pull over to let emergency vehicles move
past the trafc queue, and people seldom complain when a disabled person goes to
the front of the line.
Solo Waits Versus Group Waits
Waiting by yourself feels longer than waiting with family or friends or even with
people you do not know. Facilities that recognize this perceptual issue try to organize
their waits in such a way that people are grouped with other people. Under this logic, a
double line feels shorter than a single line, and a line structure that encourages people
to interact feels shorter than one in which people are allowed to stay inside their own
personal and highly individual spaces. In some waiting room areas, seating might be
arranged to promote interaction and a sense of being part of a group.
Uncomfortable Waits
Finding a way to keep people comfortable while they wait for treatment is a mana-
gerial challenge. Besides the obvious methods, such as providing comfortable seats
and air conditioning or heating, healthcare providers must take special care of
those with special medical needs. For example, a seriously injured person is im-
mediately given pain medication, and a comfortable bed is quickly found for the
victim of a possible heart attack.
Uninteresting Waits
Because most people like to talk about themselves, they will be interested in con-
versing with someone who asks them questions. Having a nurse or a clinical as-
sistant ask questions, take body measurements, and generally pay attention to the
patient will make the wait time more interesting. Providing interactive games and
other pleasant distractions may also make the wait more interesting.
Other Considerations
In all of these waiting situations, the customers emotional state will have a signi-
cant impact on the wait for service. Different people react differently to anxiety,
Chapter 12: Waiting for Healthcare Service 327
uncertainty, pain, and other perceived inuences on the waiting time. If the wait-
ing line is composed of people with diverse needs, the typical customer may drive
the design of the line and the associated wait. Although managers must consider
individual needs as much as possible in designing and managing waits, the queue
for a large customer volume must be designed to accommodate the waiting expec-
tations of a typical, average customer.
However, if the people in line are a more select clientele with identiable features
(e.g., big donors), then variability in treatment of the waiting customers should be
planned to meet that groups expectations for an upscale level of service. Making
the wait enjoyable or at least bearable is harder to do for a mass-market customer
base than for a select, known clientele.
In all of these waiting situations, the contrast effect will also inuence the percep-
tion of the wait. If a customers rst wait is comfortable, totally explained, and pre-
dictable, and the second wait is unpredictable, anxiety producing, and of uncertain
length, the second wait will feel longer and less satisfying than the well-managed
rst wait. Similarly, if a customer has just had a long wait, a short one will feel
even shorter in contrast. If the customer has just been in a waiting situation where
employees were friendly and all staff were busy assisting customers, that wait will
in retrospect seem shorter than a wait of identical length in which employees seem
unfriendly and engaged in activities other than serving people who are waiting.
The key is to remember that the customer perceives the wait through his par-
ticular perspective despite the reality. If the objective data say the wait at your facil-
ity is not too long or the average wait at your organization is shorter than it is at a
competitors, those data do not matter to customers who think they have waited
too long for your service. Customers have mental clocks that tell them when the
wait is too long and when it is just right and extremely well managed. Managing
the perception is as effective a technique as managing the actual waiting time, and
if the organization is particularly good at managing perceptions, it can make even
very long waits acceptable and tolerable to customers.
Perceived Value of Service
The more value the customer receives or expects to receive from the service, the
more the customer will wait without complaining or being dissatised. Because the
customer denes the value of services rendered, the perceived value of the service
for which the customer is waiting must be managed. This strategy can be imple-
mented before, during, or even after the service is performed.
Before receiving the service, waiting customers can be provided with informa-
tion (or even with some other service) that will enhance the value of the service
328 Achieving Service Excellence
that motivated them to enter the queue in the rst place. A health spa or wellness
center, for example, can offer customers waiting in line healthy snacks or fruit or
can play chamber music in the background. Such thoughtful touches not only
distract and occupy the customer but also add value to the experiences that the spa
and center are selling and for which the customer must wait.
During the performance of the service, its value (to the customer and as dened
by the customer) can be enhanced over the customers expectations by a number
of strategies. The organization will want to use these strategies in any event, but if
the service meets or exceeds expectations when the customer gets it, the wait will
probably seem worthwhile. Besides providing customers with a service that is be-
yond their expectations in the rst place, some subtle actions can enhance the value
of the service experience. For example, some hospitals display their accreditation
certicate, and some doctors display diplomas from medical schools to indicate the
quality of their training. These touches tend to encourage the patient to think the
medical treatment was worth the wait.
As a more direct response to the wait, the service provider can apologize for
and explain any unusual factors that may have caused the wait. Apologizing adds a
personal touch that may enhance the value of the experience for the customer. For
example, a family physician extends his apologies to patients in the waiting room
when he is running late on schedule. He says, It never fails to bring smiles when I
acknowledge that the patients time is as important as mine (Weiss 2003, 81).
Today, many healthcare organizations instruct their medical staff to apologize
for inevitable waits, while other hospitals ask staff to act as patients so that they
can understand what service waits feel like. Increasing their sensitivity to patient
waits raises the possibility that staff will proactively engage the waiting patients and
better manage their experience.
After the service, the value of the experience can sometimes be enhanced to
make the customers feel better about having taken the time to wait in the rst
place. Although advertising is generally used to attract the attention of potential
customers, people who have already purchased services are even more attentive to
ads than those who have not. The ads reinforce their wisdom in not only purchas-
ing the service but also waiting in line to do so. Ads seen ahead of time can also
reduce the effects of the wait while it is in progress; by convincing customers that
the experience will be worth the wait, they will wait more patiently. Some organi-
zations have found that a follow-up phone call asking a customer for reactions to
the service can enhance the value of the experience and reduce the negative effects
of the wait.
Chapter 12: Waiting for Healthcare Service 329
CONCLUSI ON
Managing the customers wait is a fundamental challenge for healthcare managers.
Service cannot be stockpiled or inventoried, and the organization must nd the right
balance between having enough physical and personnel capacity to ll demand and
having so much capacity that some healthcare services sit idle most of the time. In a
perfect world, the ow of customers exactly matches the supply: When one patient
leaves the facility, another walks in the door seeking medical care; when the physician
nishes with one patient, another arrives; and so on across the entire range of services
offered by healthcare organizations. In our less-than-perfect world, effective queue
management can get patients into the medical setting and meet their time expecta-
tions to their satisfaction.
Service Strategies
1. Manage the wait; do not just let it happen.
2. Know how long customers are willing to wait without becoming
dissatised.
3. Know the psychology of waits and manage waits to minimize customer
dissatisfaction.
4. Use queuing or waiting-line models to understand how queues work.
5. Build in adequate capacity, and manage demand by calculating and
implementing design days and capacity days.
6. Minimize the negative effects of the wait before, during, and after the
healthcare experience.
7. Create and implement performance standards for waiting times.
8. To better balance capacity with demand, nd out how much a dissatised
customer costs the organization.
This page left intentionally blank.
331
Standardsbeing able to specify what good, bad, and great service look like
are prerequisites to asking people to deliver.
Karl Albrecht and Ron Zemke
C H A P T E R 1 3
Measuring the Quality
of the Healthcare Experience
Service Principle:
Measure the important things, and then pursue
the superb healthcare experience relentlessly
All customers expect to have an outstanding experience every time. Even
though they know perfection is elusive, they hope that whatever errors happen will
not happen to them. All healthcare organizations face rising patient expectations
and patients who are increasingly unwilling to settle for less than they think they
are entitled to. Customer activism coupled with growing access to information
have made service quality more important than ever as healthcare managers strive
to identify and meet heightened patient expectations for their healthcare experi-
ences.
Service quality has become an important competitive advantage in todays
healthcare market (Berry 2009). Indeed, some evidence suggests that the process
quality of providing healthcare (the how) is as important as the clinical quality (the
what) (Marley, Collier, and Goldstein 2004). Because most patients are unable to
accurately assess the quality of their clinical care, they rely on the quality of the
processes they observe and the way they are treated to determine the quality of
their patient experience (Otani, Kurz, and Harris 2005).
Consequently, the Malcolm Baldrige award for excellence in healthcare includes
focus on patients, other customers and markets as one of the assessment factors.
Research continues to suggest that the Baldrige criteria affect patient satisfaction
(Goldstein and Schweikhart 2002; Naveh and Stern 2005). Healthcare providers
that seek this prestigious award are paying more attention to both clinical quality
in patient care and the process by which this care is delivered.
332 Achieving Service Excellence
An obvious way of creating a awless experience for tomorrows patients is for
the organization to know what errors are being made or what problems are oc-
curring now. Therefore, measuring the quality of the healthcare experience is an
increasingly important part of the leadership responsibility of the healthcare orga-
nization (Marley, Collier, and Goldstein 2004). Satised patients prefer to come
back to the healthcare provider that met or exceeded their expectations for clinical
and patient experience outcomes. Dissatised patients seek to go somewhere else
when they have other healthcare options (Boshoff and Gray 2004; Rohini and
Mahadevappa 2006).
The best time to nd out about possible problems in the patient experience is
before the patient leaves the healthcare facility, while the information is still fresh
in the patients mind. Finding out on the spot also gives the organization the op-
portunity to recover from problems before the patient leaves angry over some error
or mistake that might have been corrected if someone had asked.
Accurately measuring what patients think about their experience in physical
therapy, their overall hospital stay, or their experience in obtaining laboratory tests
is a difcult challenge for healthcare organizations striving to achieve service excel-
lence. Nevertheless, it must be donepreferably before the patient leavesand its
best to do this consistently and carefully.
In this chapter, we address the following:
How the patient perceives the quality of the healthcare experience
How healthcare managers can see problems from the patients perspective
Measurement methods that show the organization where it needs to improve
or change its service, setting, and delivery system to meet patient expectations
The critical challenge for healthcare managers is identifying and implementing the
methods that best measure the quality of the experience from the patients point of
view. As we have stated throughout this book, the patient determines quality and
value. Consequently, what is an acceptable experience for one patient might be a
superb experience for another and a serious problem to a third.
The subjective nature of the quality and value of a healthcare experience makes
identifying and implementing the appropriate measurement particularly difcult.
No matter how well management or the medical staff plan a treatment, surgery,
or therapy, the quality of the healthcare experience cannot be measured until the
patient experiences it.
A variety of methods are available to measure the quality of the healthcare experi-
ence. These methods differ in cost, accuracy, and degree of patient inconvenience.
Chapter 13: Measuring the Quality of the Healthcare Experience 333
Measuring healthcare quality can have many organizational benets, but as usual
the benets must be balanced against the costs of obtaining them.
In other words, the organization must balance the information needed and
the extent and precision of the research expertise required to gather and in-
terpret it against the availability of funding. As a rule, the more accurate and
precise the information, the more expensive it is to acquire. Typically, organiza-
tions use both qualitative and quantitative methods. Each will be discussed in
the sections that follow.
QUALI TATI VE METHODS
Qualitative techniques are generally less expensive than quantitative methods.
Exhibit 13.1 outlines the major qualitative techniques and their advantages and
disadvantages. The qualitative techniques include management observation, em-
ployee feedback programs (e.g., work teams, quality circles), and focus groups.
Qualitative measures should have a quantitative component. Excellent health-
care managers seek to make quantitative even the most qualitative assessments by
systematically recording what they observe or hear. If a manager encounters an
angry patient with a complaint, the manager should have a record that four previ-
ous angry patients said the same thing. This systematic approach allows even the
most qualitative assessment process to take on many of the benecial features of
the most quantitatively precise process.
Management Observation
The simplest and least expensive technique for assessing quality is to encourage
managers to keep their eyes open, especially to the interactions between staff and
patients and other customers, and to talk to employees and patients. This tech-
nique has been called management by walking around, or MBWA. Some health-
care organizations, borrowing a term from the restaurant industry, call it walking
the front, which means observing what is happening rsthand, looking for prob-
lems or inefciencies, talking to patients and staff to assess their reactions, nding
solutions to any patient problems encountered, and sharing with staff any informa-
tion that might enable them to improve the healthcare experience. More recently,
other healthcare experts have borrowed the term rounding from the clinical side
to describe this managerial technique. Indeed, Studer (2008) is so convinced of the
3
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Table 14.1 Advantages and Disadvantages of Various Qualitative Techniques for Measuring Patient Service Quality
Management
T s e g a t n a v d a s i D s e g a t n a v d A s e u q i n h c e
Management Management knows business, policies, and Management presence may influence service
s r e d i v o r p s e r u d e c o r p n o i t a v r e s b o
y t i l i b a i l e r d n a y t i d i l a v l a c i t s i t a t s s k c a L t n e i t a p o t e c n e i n e v n o c n i o N
Opportunity to recover from service failure Objective observation requires specialized training
Opportunity to obtain detailed patient feedback Employees disinclined to report problems they
Opportunity to identify service delivery problems created
Minimal incremental cost for data gathering Management may be unfamiliar with processes
and customers
Employee Employees have knowledge of service delivery Objective observation requires specialized training
y e h t s m e l b o r p t r o p e r o t d e n i l c n i t o n s e e y o l p m E s e l c a t s b o k c a b d e e f
programs Patients volunteer service experience information created
to employees
No inconvenience to patients
Opportunity to recover from service failure
Opportunity to collect detailed patient feedback
Minimal incremental cost for data gathering and
documentation
Work teams Develops employee awareness of managements Employees may wish to avoid responsibilites of
and quality strong commitment to service quality empowerment
circles Develops an understanding and appreciation of Team may not act cohesively and work together
how each employee can directly influence service Necessary communication among team members
e m i t f o t n u o m a e g r a l s e k a t y t i l a u q
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Exhibit 13.1 Advantages and Disadvantages of Various Qualitative Techniques for Measuring Patient Service Quality
(Continued)
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Table 14.1 (continued)
Work teams Through empowerment, improves employee morale,
and quality productivity, efficiency, effectiveness, and patient
circles (cont) satisfaction
Team working together conveys confidence and
competence to patients
Focus groups Opportunity to collect detailed patient feedback May only identify symptoms and not core service
Opportunity to recover from service failure delivery problems
Qualitative analysis helps to focus managers on Feedback limited to small group of customers
s l i a t e d r e t n u o c n e e c i v r e s c i f i c e p s f o n o i t c e l l o c e R s a e r a m e l b o r p
Other problems may surface during discussions may be lost
Suggests that facility is interested in patients One group member may dominate or bias discussion
r o f s e v i t n e c n i s e t a t i s s e c e n e c n e i n e v n o c n I y t i l a u q e c i v r e s f o s n o i n i p o
participation
High cost of properly trained focus group leader
Information may be withheld due to fear of
disapproval by others
May not be representative sample of the patient
population
Service Provides feedback on service failures in significant Self-selected sample of patients not statistically
e v i t a t n e s e r p e r s a e r a s e e t n a r a u g
Enhances both measurement and marketing Some patients may take advantage of organization
Source: Adapted with permission from R. C. Ford, S. A. Bach, and M. D. Fottler, Methods of Measuring Patient Satisfaction in Health Care
Organizations, 22 (2), page 77, 1997, Aspen Publishers, Inc.
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Exhibit 13.1 (continued)
336 Achieving Service Excellence
merits of this tool that he devotes two chapters in his book to roundingone on
rounding with employees and one on rounding with customers.
Managers know their own healthcare operation and its goals, capabilities, and
healthcare quality standards. They know, at least from the managerial perspective,
when staff members are delivering a high-quality experience.
Managerial observations do not inconvenience patients or staff, and they often
permit immediate correction of patient-service problems. Everyone, including pa-
tients, appreciates being asked by a manager what he or she thought of the experi-
ence. Asking is strong evidence that the organization cares about service quality
and is committed to helping employees deliver it.
Furthermore, managerial observation gives supervisors the opportunity to
recognize, reinforce, and reward an excellent employee and coach an employee
who might not be delivering the service as it should be delivered. It also provides
a teaching opportunity where a supervisor who observes a service problem can
model the way to x it. Moreover, when managers walk the front to act as coaches
and not as spies, their presence has a favorable inuence on employee attitudes and
performance as well as on patient satisfaction.
Relying only on managerial observation for assessing service quality has its
downsides, however. Some managers may not have enough experience or training
to fully understand what they are observing; they may have biases that inuence
their objectivity; they may not know how to effectively coach an employee or
handle a distraught customer; or they may be too busy with paperwork or unwill-
ing to make the time to actively observe.
Also, when employees know managers are observing the service delivery pro-
cess, they invariably perform it differently. In addition, although management ob-
servation may ensure the quality of the experience for a particular patient, even
the most energetic manager cannot watch every patientemployee interaction. An
unobserved patients reactions to an unobserved experience remain unknown to
the manager.
Training healthcare managers in how to observe employeepatient interactions,
measure these interactions against quality standards, and coach providers and em-
ployees can eliminate or at least reduce personal bias. Managers may think they
have no time to observe interactions, but they could be wrong when they review
their own time usage. Unobtrusive observational techniques, random observations,
and video cameras can diminish employee awareness that the boss is watching.
For example, many organizations tell their telephone operators and callers that
all phone conversations may be monitored for training purposes to eliminate the
observation bias by making it uncertain when management is actually listening in.
The operators know someone may always be listening, so they do the job by the
book. Some larger companies use managers from one location to observe employ-
Chapter 13: Measuring the Quality of the Healthcare Experience 337
ees at another location for the same reason. The increasing use of video monitoring
to enhance security has had the unintended but benecial consequence of encour-
aging employees to think of themselves as being under constant supervision. For
obvious ethical reasons, employees and customers should be alerted that they may
be monitored.
Employee Feedback
Employee feedback should supplement management observation. Employees can
provide input on such issues as cumbersome organizational policies and control
procedures, managerial reporting structures, or other processes that inhibit effec-
tive healthcare service delivery. They know rsthand about organizational impedi-
ments that prevent them from delivering high-quality service (Gupta 2008).
In fact, a study by the authors (Fottler et al. 2006) found that a focus group of
employees identied the same problems with more detail than a customer focus
group. This raises the possibility of using employee focus groups as a less expensive
alternative to customer focus groups or even employee surveys for discovering is-
sues and concerns in the healthcare organization that interfere with patient service
quality. The study concluded that employees know what is wrong with the patient
experience and are glad to tell when management asks.
Employee work teams and quality service circles are other sources of feedback.
Such techniques foster an understanding and appreciation of how each employee
can directly inuence service quality. Employee awareness of managements strong
commitment to healthcare quality is afrmed when work teams are asked to review
all aspects of the customer service experience. Use of work teams requires the or-
ganization to invest in employee training and to allow team members the time to
meet. This step sends two important messages: (1) Management trusts employees
ability to nd and x problems, and (2) the organization is truly committed to
service if it spends precious resources on providing it.
Another employee feedback process is the patient ombudsman position. The
ombudsman is responsible for seeking out patients to hear their concerns and re-
porting these problems to someone who can address them, if the ombudsman does
not have the ability to x them. Generally, the ombudsman is viewed as a resource-
ful, friendly, trustworthy employee to whom customers can air out their grievances
without fear of repercussions. Typically, the ombudsman reports directly to a se-
nior manager who oversees patient satisfaction efforts.
For example, in one hospital, the cheer bringer, who previously delivered
cards and owers to patients, was given the ombudsman role after management
realized that the hospital had no formal complaint procedure. Inpatients were not
338 Achieving Service Excellence
likely to complain about the staff as they feared retaliation or mistreatment. With
her new ombudsman role, the cheer bringer went around asking patients of their
concerns. Because the cheer bringer was already a well-liked and trusted staff mem-
ber, she was the ideal person to approach patients about their complaints.
Focus Groups
Focus groups provide in-depth information on how patients and other customers
view the service they receive. Typically, a focus group of six to ten persons gath-
ers with a facilitator for several hours to discuss real or imagined problems and to
make suggestions. Many service organizations routinely invite customers to par-
ticipate in focus groups. These invitations show customers that the company cares
enough about their reactions to ask them to participate, and customers appreciate
the dollars, complimentary dinner, or other expression of appreciation that typi-
cally compensates them for their time.
One reason organizations use focus groups is to supplement survey results,
which often fail to produce information that is useful for program improvement
because the information is not discriminating or comprehensive enough (Berry
2009). Surveys only tell management what the survey measures and not necessarily
what is really important to the patient. Surveys may only ask for satisfaction ratings
about areas that are not key drivers of customer (patient and staff ) satisfaction.
Surveys generally are limited to asking about what happened in the past and not
about what the patient desires in the future. In addition, surveys rely on patients
memories of experiences they are frequently eager to forget. Finally, surveys may
too narrowly frame the range of possible responses, which could result in overesti-
mating satisfaction (Fottler et al. 2006).
Patient focus groups can provide valuable feedback about what patients expect,
and they are particularly effective in identifying factors patients nd important or
missing (Fottler et al. 2006). Because focus group questions are open ended and
amplication is invited, participants experiences, opinions, expectations, and sug-
gestions are likely to be richer in content and context than survey data.
Service Guarantees
The service guarantee method is based on a given customers subjective perception
of whether an aspect of the service was or was not completely satisfactory. Prom-
ises such as satisfaction guaranteed or your money back; no questions asked and
Chapter 13: Measuring the Quality of the Healthcare Experience 339
satisfaction guaranteed or get 50 percent off your next purchase have worked well
across the service industry. A longitudinal study by Hays and Hill (2006) found
that service guarantees have a positive, long-term effect on both employee motiva-
tion and customer intention to return. This study strongly supports using a service
guarantee to improve customer loyalty and to increase employee motivation.
JetBlue is one organization that provides a service guarantee, and that guarantee
is spelled out in its customer bill of rights (Airoldi 2007):
JetBlue compensates customers if, as a result of JetBlues decisions, an airplane
takes more than 30 minutes to reach the gate after it lands.
For arrival delays, customers receive vouchers applicable to the purchase of
future ights: $25 for delays of up to 1 hour, $100 for delays of 1 to 2 hours,
the cost of a one-way ticket identical to the one purchased for a
2- to 4-hour delay, and the cost of a roundtrip ticket for delays of more
than 4 hours.
JetBlue gives customers a $100 voucher for departure delays of 3 hours and
a voucher for a new trip after 4 hours. People are removed from the airplane
after delays of 5 hours.
JetBlue provides customers with $1,000 in cash, rather than the $400 the
federal government requires, if they are ever denied boarding.
By contrast, such guarantees and patient bills of rights are quite rare in health-
care. According to one classic study, the average business spends six times more
money on marketing to potential new customers than it does working to keep the
customers it has (Sherman and Sherman 1998, 164). Some evidence suggests that
acquiring new customers is cheaper than retaining current ones, but some health-
care insiders argue for the exact opposite (East, Hammond, and Gendall 2006).
Healthcare facilities focus their marketing programs on recruiting new custom-
ers, yet they typically offer no quality or satisfaction guarantees to their current or
prospective customers to assure them of the excellence of their healthcare service.
So why do healthcare organizations not offer guarantees that are similar to those
offered by other service businesses? They should be able to at least guarantee that
staff will answer the phone in a reasonable period of time, patient paperwork will
be minimized, food will equal restaurant quality, wait times at discharge and clini-
cal locations will be minimal, all facilities will be clean, and staff members will be
friendly and respectful.
According to Fabien (2005), service guarantees provide a number of im-
portant advantages to organizations, including organizational learning. If a
company has a strong and well-understood service guarantee that is invoked
340 Achieving Service Excellence
by its customers, everyone in that organization learns about the service deliv-
ery system. Similarly, Hart (1988) lists several important benets of a service
guarantee:
It forces everyone to think about the service from the customers point of view
because the customer decides whether or not to invoke it.
It pinpoints where the service failed because the customer must give
the reason for invoking the guarantee, and that reason then becomes
measurement data on the service delivery system. A patient complaint
is a good thing for a healthcare organization that hopes to be perfect.
Guarantees are an incentive to get customers to complain if their
expectations (and the guarantees terms) have not been met, and these
complaints then help the organization to x whatever is wrong before
other customers have problems.
It gets everyone to focus quickly on the problem at hand because the costs of
making good on guarantees can be quite large. Once a customer has to invoke
the guarantee, the cost of the lost revenue forces management to direct its
attention at correcting the problem.
It enhances the likelihood of recovery from a service problem because the
patient is encouraged to demand instant recovery, instead of writing a
complaint letter and taking the business to a competitor.
It sends a strong message to employees and customers alike that the
organization takes its healthcare quality seriously and will stand behind it.
Sidebar A provides classic service guarantee criteria from Hart (1988).
QUANTI TATI VE METHODS
Although qualitative methods for assessing service quality have their benets, good
organizations are even more interested in measuring what patients themselves (and
sometimes their families) think about their experiences in some quantitative for-
mat. Patients are typically willing to tell healthcare providers what they liked or did
not like about their experience. Studer (2008) stresses the importance of this. A
large body of literature describes a variety of techniques to gather patient satisfac-
tion and perceptions of service quality data (e.g., National Quality Forum 2005;
Ford, Bach, and Fottler 1997). Techniques to collect data directly from patients
vary in cost, convenience, objectivity, and statistical validity.
Exhibit 13.2 provides an overview of patient-sourced quantitative methods and
shows the advantages and disadvantages of each technique.
Chapter 13: Measuring the Quality of the Healthcare Experience 341
Performance Standards
Outstanding organizations develop quantitative performance standards and mea-
surements so that employees can monitor their own actions. Some standards are
used throughout the industryfor example, 3 minutes to respond to a Code Blue,
20 minutes for breakfast trays to be served after arriving on the oor, and 5 min-
utes for a room call light to be answered.
Most standards are specic to the organizations that create them and are de-
signed to meet or beat the competition and to meet patient expectations. Emer-
gency departments dene how many minutes it should take for a newly arrived
patient to be triaged. If it has not happened in, say, 5 minutes, then the healthcare
quality standard has not been met. Nurses may use a measure of the number of
SIDEBAR A:
CRITERIA FOR A SERVICE GUARANTEE
1. Unconditional. The more asterisks or conditions
attached to the bottom of the page and the
more ne print, the less credible the guarantee
will seem to employees and customers. Few
or no conditions should be required to use the
guarantee.
2. Easy to understand and communicate. The
more complicated the guarantee is, the less
likely anyone will believe or use it.
3. Focused on the customers needs. The
guarantee should solve the customers
problems, not fit the organizations
needs.
4. Clear on defining the standard for healthcare
quality. If you are going to guarantee
it, you better deliver it the way you are
supposed to.
5. Meaningful to the customer and the
organization. If invoking the guarantee only
partially solves the customers problem or
is of little consequence to the organization,
neither the customer nor the service people
will value the guarantee.
6. Easy to use. Invoking the guarantee and
receiving its benets should be painless for
the patient. The harder a guarantee is to
use, the less credible it will be, and the less
likely it will help identify serious service
problems.
7. A declaration of trust. This trust extends to
the customers you are trusting to use it only
when they have a legitimate complaint and
the employees you are trusting to correct
the customers problem quickly, fairly, and
effectively without giving away the whole
organization.
8. Credible or believable by the customer. If
customers do not believe you will really
make good, then they will not use the
guarantee.
Source: Adapted by permission of Harvard Business Review from The Power of Unconditional Service
Guarantees, by C. W. L. Hart, 66 (4): 5462. Copyright 1988 by the Harvard Business School of Pub-
lishing Corporation; all rights reserved.
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Table 14.2 Advantages and Disadvantages of Various Quantitative Techniques for Measuring Patient Service Quality
Management
Techniques Advantages Disadvantages
Comment Suggests that facility is interested in patients Self-selected sample of patients not statistically
cards opinions of service quality representative
Opportunity to recover from service failure Comments generally reflect extreme patient
Minimal incremental cost for data gathering dissatisfaction or extreme satisfaction
Moderate cost
Mail surveys Ability to gather representative and valid Recollection of specific service encounter details
samples of targeted patients may be lost
Opportunity to recover from service failure Other service experiences may bias responses
Patients can reflect on their service experience because of time lag
Suggests that facility is interested in patients Inconvenience necessitates incentives for participants
opinions of service quality Cost to gather representative sample may be high
Allows comparisons of patient satifaction by Potential problems with the wording of questions
department and patient demographics
On-site Opportunity to collect detailed patient feedback May not be representative sample of patients
personal Opportunity to recover from service failure Other service experiences may bias responses
interviews Ability to gather representative and valid sample Respondents tend to give socially desirable responses
of targeted patients Inconvenience necessitates incentives for participants
Suggests that facility is interested in patients Cost moderate to high
opinions of service quality
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Exhibit 13.2 Advantages and Disadvantages of Various Quantitative Techniques for Measuring Patient Service Quality
(Continued)
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Table 14.2 (continued)
Telephone Opportunity to collect detailed patient feedback Individuals tend to find telephone calls intrusive
interviews Ability to gather representative and valid sample Difficult to contact people at work; inconvenient
e m o h t a s t n e i t a p d e t e g r a t f o
Opportunity to recover from service failure Costs of skilled interviewers and valid instrument
Suggests that facility is interested in patients are high
f o n o i t c e s - s s o r c e v i t a t n e s e r p e r a e t a r e n e g t o n y a M y t i l a u q e c i v r e s f o s n o i n i p o
patients
Mystery Consistent and unbiased feedback Snapshot of isolated encounters may be
d i l a v n i y l l a c i t s i t a t s s n o i t a u t i s c i f i c e p s n o s u c o f n a C s r e p p o h s
h g i h o t e t a r e d o m t s o C t n e i t a p o t e c n e i n e v n o c n i o N
Opportunity to collect detailed customer feedback Not applicable to all clinical areas (e.g., surgery)
Allows measurement of training program Ethical concerns
effectiveness
Source: Adapted with permission from R. C. Ford, S. A. Bach, and M. D. Fottler, Methods of Measuring Patient Satisfaction in Health Care
Organizations, 22 (2), page 81, 1997, Aspen Publishers, Inc.
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Exhibit 13.2 (continued)
344 Achieving Service Excellence
rings for answering a patient call. If a nurse has not responded to the call within a
certain number of rings, the quality standard has not been met.
These are examples of the types of standards that can be developed, measured,
and used as ways to ensure that the healthcare experience is delivered as it should
be. In his classic work Quality Is Free, quality expert Phillip Crosby (1978) notes
that the price of not conforming to a quality standard can be calculated as the cost
to x errors and failures that result from not meeting quality standards in the rst
place. Some organizations may think that determining the cost of not answering
the phone within three rings is impossible, but healthcare experts are convinced
otherwise (e.g., Studer 2008).
To prevent customer service problems, an organizations own performance stan-
dards should exceed those of all but the most demanding patients. If they do, the
organizations internal control measures may sometimes show that a standard has
not been met, even if patients seem satised and no one complains. When that
happens, some organizations in the service industry actually apologize.
Patients will remember healthcare organizations that behave this way as much
as they remember other service organizations that have learned the power of the
apology. Healthcare executives may fear that offering apologies may lead to a law-
suit, because an apology may seem like an admission of liability, but benchmark
healthcare organizations have learned how to gain the benets of offering apologies
without admitting liability.
Comment Cards
Comment cards are the cheapest and easiest to use of all data-collection methods.
If properly designed, they are easy to tally and analyze. These advantages make
them attractive for gathering patient satisfaction data, especially for smaller orga-
nizations that cannot afford a quality assessment staff or consultants. Comment
cards rely on voluntary patient participation and involve patients rating the quality
of the healthcare experience by responding to a few simple questions on a con-
veniently available form, typically a postcard. Patients deposit the form in a box
placed near the healthcare facility exit, return it directly to the service provider, or
mail it to the organizations ofce.
Following are six reasons to use comment cards (Szwarc 2005):
1. To identify the particular needs and concerns of each major customer group
2. To be able to quickly and accurately assess the impact of service improvements
from the customers point of view
Chapter 13: Measuring the Quality of the Healthcare Experience 345
3. To speed up the feedback cycle, so customer input is gathered quickly
4. To have an easy method for getting candid feedback from customers
5. To supplement anecdotal feedback with quantitative data
6. To have a systematic way to nd problems when you are implementing service
improvements
To develop a useful comment card, a healthcare organization should identify
its customers for particular services, study these customers, and nd out what is
important to them in terms of service. Once these expectations have been de-
termined, comment-card questions are developed. If studies reveal that patients
expect a friendly greeting, prompt attention, and detailed information about the
treatment procedure when they visit a physicians ofce, the ofces comment card
will ask patients about those elements of the healthcare experience. If an organiza-
tion tries to differentiate itself from similar organizations in some particular way,
that differentiating factor may also appear on the comment card, so that the orga-
nization can gauge the success of its differentiation strategy.
Comment cards give an indication of whether the organization is meeting the
general expectations of the customers who take the time to ll them out. Written
comments about long call-response waits, lines at the reception desk, or house-
keeping problems reveal the strengths and weaknesses of the service delivery sys-
tem, the personnel and their training, and the service itself.
Positive comments can also provide management with the opportunity to rec-
ognize employee excellence. This recognition reinforces the behaviors that lead
to good patient service and creates role models and stories about how to provide
outstanding service that other employees can use in shaping their own behavior in
their jobs. Negative comments can be used in training, without mentioning spe-
cic employees, to illustrate behaviors that caused negative healthcare experiences.
Using comment cards in these ways allows managers to train employees in how to
provide excellent patient service through the voices of the patients themselves.
Comments accumulated from cards may be plotted as numerical values on bar
graphs and charts that visually display how patients perceived their experience. The
plots will suggest whether service problems are occurring occasionally and ran-
domly, or whether overall service quality might be deteriorating. Although patient
comments and their visual representations are interesting and helpful to manage-
ment, the information is not statistically valid because, for one, the random-sample
requirement of most statistical techniques is not met.
The greatest disadvantage of comment cards is that many customers ignore
them and do not ll them out, so the cards received are not likely to be a true gen-
eral picture of the customers perceptions. Typically, only 5 percent of customers
346 Achieving Service Excellence
return comment cards, and they are usually either very satised or very dissatised.
It is difcult to know what percentage of the delighted total or the dissatised
total these responses represent. When the other 95 percent of customers say noth-
ing, the healthcare organization cannot determine if they were happy, unhappy, or
merely indifferent. Research shows that a large percentage of dissatised customers
ll out no cards, leave quietly, and never return.
Another major disadvantage of comment cards, and in fact of many methods
for acquiring feedback, is that the time lag between patient response and manage-
rial review prevents on-the-spot correction of service gaps and problems. Once the
moment of truth has passed and the angry or disappointed patient leaves after ex-
pressing negative responses on a comment card, the opportunity to recapture that
patients future business or loyalty is diminished.
Even worse, negative word-of-mouth advertising generated by dissatised pa-
tients cannot be corrected. Any time patients are asked to provide negative feed-
back, they must be assured that their identity will not be revealed to prevent any
kind of recriminations.
Surveys
Formal survey methods can obtain patient feedback about healthcare quality and
value. Although surveying is more expensive than the methods already discussed,
surveys can offer statistically valid, reliable, and useful measures of patient opinion
that the other methods cannot. Surveys can range in sophistication, precision, va-
lidity, reliability, complexity, cost, and difculty of administration.
Mail Surveys
Well-developed mail surveys, sent to an appropriate and willing sample, can pro-
vide valid information concerning patient satisfaction. Organizations can use mail
surveys to their benet, but many uncontrollable factors can inuence patient re-
sponses to a mail survey. Inaccurate and incomplete mailing lists or simple lack of
interest in commenting can produce a response rate too small to provide useful
information. In addition, the time lag between the experience and survey response
can blur a patients memory of details.
Mail surveys are usually used to generate reports that tend to be upwardly bi-
ased. The subtleties of the healthcare experience and patient perceptions cannot be
fully expressed numerically. Also, averages may not be sufciently informative. If
some patients remember an experience as terric and give it a high rating, while
others rate it as terrible, the numerical average will suggest that, on the average,
patient expectations were met.
Chapter 13: Measuring the Quality of the Healthcare Experience 347
The nature of medical treatment may also make interpretation of the ratings
difcult. If the operation was a success but the patient died, it would not matter
to the surveyed survivors that the rest of the patients experience was above expec-
tations. Finally, formal mail survey techniques are expensive because they require
proper questionnaire development, validation, and data analysis.
SERVQUAL
Several measures of service quality are available (see, for example, Castle 2007;
Gupta 2008; Marley, Collier, and Goldstein 2004). One well-accepted survey
technique is SERVQUAL (short for service quality), developed by Parasuraman
and his associates (Parasuraman, Zeithaml, and Berry 1988). SERVQUAL,
which has been extensively researched to validate its psychometric properties,
seeks to measure the way customers perceive the quality of service experiences
in ve categories:
1. Reliability: The organizations ability to perform the desired service
dependably, accurately, and consistently
2. Responsiveness: The organizations willingness to provide prompt service and
help customers
3. Assurance: The employees knowledge, courtesy, and ability to convey trust
4. Empathy: The employees ability to provide care and individualized attention
to customers
5. Tangibles: The organizations physical facilities and equipment and appearance
of personnel
SERVQUAL also asks respondents to rate the relative importance of the ve
areas, so organizations can make sure they understand what matters most to cus-
tomers. In each area, SERVQUAL asks customers what they expected and what
they actually experienced to identify service gaps at which organizations should
direct attention.
The SERVQUAL index was developed for the retail and other service indus-
tries. Ramsaran-Fowdar (2005) studied the SERVQUAL measures and identied
additional service dimensions relevant to healthcare, including core medical out-
comes (e.g., patient education, physician referral contacts) and professionalism
(e.g., knowledgeable and skilled support staff ).
SERVQUAL has been widely used in healthcare organizations (Rohini and Ma-
hadevappa 2006; Pakdil and Harwood 2005) with varying results (Dagger, Sweeney,
and Johnson 2007; Ramsaran-Fowdar 2005). An adaptation of the SERVQUAL
survey instrument, intended to evaluate service quality at Hallmark Hospital, is
presented in Exhibit 13.3.
348 Achieving Service Excellence
Exhibit 13.3 SERVQUAL Application to Healthcare: Measuring Customer Perceptions of
Healthcare Quality at Hallmark Hospital
, achi evi ng s ervi ce excel l ence
Figure 14.1 SERVQUAL Application to Healthcare: Measuring Customer
Perceptions of Healthcare Quality at Hallmark Hospital
DIRECTIONS: Listed below are five features pertaining to Hallmark Hos-
pital and the services it offers. We would like to know how important
each of these features is to you when you evaluate a hospitals quality.
Please allocate a total of 100 points among the five features according
to how important each feature is to youthe more important a feature is
to you, the more points you should allocate to it. Please ensure that the
points you allocate to the five features add up to 100.
1. The appearance of the hospitals physical facilities, equipment, and
personnel
________ points
2. The ability of the hospital to perform the promised service dependably
and accurately
________ points
3. The willingness of the hospital to help customers and provide
prompt service
________ points
4. The knowledge and courtesy of the hospitals employees and their
ability to convey trust and confidence
________ points
5. The caring, individualized attention the hospital provides to its customers
________ points
DIRECTIONS: Based on your experience with hospitals, please think
about the kind of hospital at which you would prefer to receive health-
care. Please show the extent to which you think such a hospital would
possess the feature described by each statement below. If you feel a fea-
ture is not at all essential for excellent hospitals such as the one you have
in mind, circle 1 for Strongly Disagree. If you feel a feature is absolutely
essential for excellent hospitals, circle 7 for Strongly Agree. If your feel-
ings are less strong, circle one of the numbers in the middle. There are
no right or wrong answers. All we are interested in is a number that truly
reflects your feelings regarding hospitals that would deliver excellent
service quality.
[The 22 survey items for this section are the same as those in the next section,
but without any reference to Hallmark Hospital.]
Fotter/book 8/12/02 3:47 PM Page 384
(Continued)
Chapter 13: Measuring the Quality of the Healthcare Experience 349
measuri ng the healthcare experi ence 385
Figure 14.1 (continued)
DIRECTIONS: The following set of statements relates to your feelings
about the service at Hallmark Hospital. For each statement, please show
the extent to which you believe Hallmark Hospital has the feature
described by each statement below. Once again, circling 1 means that
you Strongly Disagree that Hallmark Hospital has that feature, and cir-
cling 7 means that you Strongly Agree. You may circle any of the num-
bers in the middle that show how strong your feelings are. There are no
right or wrong answers. All we are interested in is a number that best
shows your perceptions about the service at Hallmark Hospital.
[On the instrument itself, the five category labels (Tangibles, etc.) will be
omitted.]
TANGIBLES
P1. Hallmark Hospital has modern-looking equipment
P2. Hallmark Hospitals physical facilities are visually appealing
P3. Hallmark Hospitals employees are neat-appearing
P4. Materials associated with the service are clean and sanitary at
Hallmark Hospital
RELIABILITY
P5. When Hallmark Hospital promises to do something by a certain
time, it does so
P6. When you have a problem, Hallmark Hospital shows sincere inter-
est in solving it
P7. Hallmark Hospital performs the service right the first time
P8. Hallmark Hospital provides its services in the way it promises to do so
P9. Hallmark Hospital insists on error-free service performance
RESPONSIVENESS
P10. Employees of Hallmark Hospital tell you exactly when healthcare
services will be performed
P11. Employees of Hallmark Hospital give you prompt healthcare service
P12. Employees of Hallmark Hospital are always willing to help you
P13. Employees of Hallmark Hospital are never too busy to respond to
your requests
Fotter/book 8/12/02 3:47 PM Page 385
Exhibit 13.3 (continued)
350 Achieving Service Excellence
Although tangibles refer primarily to the setting and to the physical
elements of the delivery system, and reliability reflects a combination
of organizational delivery system design and service provider ability,
the remaining three elements-responsiveness, assurance, and empa-
thy-are almost exclusively the responsibility of the patient-contact
employees.
Assessing Internal Customers
Healthcare organizations too often overlook internal customers when
they assess external customers. Many units within traditional full-serv-
ice healthcare facilities provide service functions for other internal units
either in addition to services for patients and external physicians or as
standalone functions (i.e., human resources, training, and payroll).
These internal service providers are often thought of as overhead activ-
ities rather than service providers with customers. As a result, many
healthcare executives pay little attention to these activities.
,o achi evi ng s ervi ce excel l ence
Figure 14.1 (continued)
ASSURANCE
P14. The behavior of Hallmark Hospital employees instills confidence in
customers
P15. You feel safe in going to Hallmark Hospital and doing business with
them
P16. Employees of Hallmark Hospital are consistently courteous to you
P17. Employees of Hallmark Hospital have the knowledge to answer your
questions
EMPATHY
P18. Hallmark Hospital gives you individual attention
P19. Hallmark Hospital has visiting hours convenient to all its customers
P20. Hallmark Hospital has employees who give you personal attention
P21. Hallmark Hospital has your best interests at heart
P22. Employees of Hallmark Hospital try to learn your specific needs
Source: Adapted with permission from SERVQUAL: A Multiple-Item Scale for
Measuring Consumer Perception of Service Quality, by A. Parasuraman, V. A. Zeithaml,
and L. L. Berry. 1988. Journal of Retailing 64 (1): 3840.
Fotter/book 8/12/02 3:47 PM Page 386
Exhibit 13.3 (continued)
The SERVQUAL instrument reects a point we have made throughout: the
importance of the patient-contact staff to healthcare quality. Although tangibles
refer primarily to the setting and to the physical elements of the delivery system,
and reliability reects a combination of organizational delivery system design and
service provider ability, the remaining three elementsresponsiveness, assurance,
and empathyare almost exclusively the responsibility of the patient-contact em-
ployees.
Internal Customer Metrics
Healthcare organizations too often overlook internal customers when they assess
external customers. Many units within traditional full-service healthcare facilities
provide service functions for other internal units in addition to services for patients
and external physicians or as stand-alone functions (i.e., human resources, train-
ing, and payroll). These internal service providers are often thought of as overhead
Chapter 13: Measuring the Quality of the Healthcare Experience 351
activities rather than service providers with customers. As a result, many healthcare
executives pay little attention to these activities.
One hospital developed and implemented an internal customer survey in-
strument (Smith et al. 2007). This process included (1) an initial baseline survey
of service managers concerning their satisfaction with internal nursing services,
(2) feedback to service-area managers regarding the survey results, (3) an interim
survey to determine improvement, and (4) a resurvey two years later to determine
effectiveness of the implemented changes. In general, the scores in the initial sur-
vey were highly positive. Of the 15 areas, 13 received favorable composite scores
and 11 received mean scores stronger than the agree category of 3.0.
After reviewing the results of the initial survey, senior nurse managers used
the results as a baseline for service improvement. The service-area nurse managers
picked three specic problems identied in the survey and then developed and
implemented plans to address those problems. Most of the nurse managers then
solicited staff input on these action plans. After two years, the satisfaction levels
of the customers (users of nursing services) showed that all 15 service areas were
received favorably and 14 of the 15 areas had mean scores greater than 3.0.
Researcher Ben Schneider has developed another widely used questionnaire
that seeks to assess the degree to which employees perceive a climate of service.
In a number of published studies, Schneider and colleagues have found a consis-
tent relationship between employee assessments of a positive service climate and
customers perceptions of the positive service experience (Schneider, Macey, and
Young 2006; Schneider and White 2004). Clearly, a link exists between the em-
ployee propensity to deliver excellent customer service and the actual delivery of
service quality.
Structured Personal Interviews
Face-to-face patient interviews provide rich information when trained interview-
ers, who are able to detect nuances in responses to open-ended questions, have the
opportunity to probe patients for details about their experiences. Interviewing can
uncover previously unknown problems or new twists to a known problem that
cannot be uncovered in a preprinted questionnaire or reected well in numerical
data.
However, personal interviews are costly: Interviewers must be hired and trained,
interview instruments must be custom designed, and inconvenienced patients
must be compensated for participating. Without incentives, most patients see little
352 Achieving Service Excellence
personal benet from participating in a patient interview unless they are either very
satised or very dissatised. Finally, the most desirable time to interview patients
and/or their families is at the conclusion of the healthcare experience. Getting their
attention and cooperation when they are anxious to leave is a challenge.
Another patient-interview approach is to employ consultants or employees
(called lobby lizards in the hotel business) to ask randomly selected patients their
opinions on several key service issues. In a healthcare facility, the person conduct-
ing the customer interviews is typically a manager or another patient-contact em-
ployee. For example, a billing clerk may have the best opportunity to question
patients about their experience as they are leaving the clinic, ofce, or hospital and
making their payment. Because patients may not always be motivated to tell the
whole truth, a systematic interview should pose questions that are professionally
developed and validated to help ensure that the information gathered is useful, ac-
curate, and sufcient.
As mentioned earlier, one advantage of acquiring immediate feedback is that it
may allow prompt recovery from service problems. Staff training should therefore
include appropriate service-recovery techniques, as research conrms that the or-
ganization benets greatly from soliciting and fairly resolving patient complaints.
Because service-quality information derived directly from the patient is highly be-
lievable to staff and management, it motivates a serious consideration of the prob-
lems the patients identied.
Critical Incidents
Another important survey tool is the critical incident technique. Through inter-
views or paper-and-pencil surveys, customers are asked to identify and evaluate nu-
merous momentsclassied as dissatisers, neutral, or satisersin their interac-
tions with the organization. The survey lets the organization know which moments
are critical to customer satisfaction, and the critical dissatisers can be traced back
to their root causes and rectied. The Malcolm Baldrige report of Mercy Health
System, for example, discusses the importance of the organizations critical mo-
ments of service. These events are considered key to providing patient satisfaction
and are monitored closely and updated often.
Knowing which incidents in the hospital stay are critical to patients allows the
organization to concentrate on making them smooth and seamless (Mercy Health
System 2007). In healthcare, the critical incidents tend to be related to customer
expectations (discussed earlier) such as patients concerns about personalized care,
prompt attention, staff respect, physician and staff competence, a clean environ-
Chapter 13: Measuring the Quality of the Healthcare Experience 353
ment, privacy, and clear information. Information related to these critical incidents
will generate usable information for service improvement.
Telephone and Web-Based Surveys
Telephone interviews are another useful method for assessing customer percep-
tions of service. A review of the Malcolm Baldrige award winners reveals a com-
mon use of these surveys. Many use commercial providers like Press Ganey or
Gallup to gather this information, and others, such as Sharp HealthCare and
Mercy Health System, collect these data monthly. Many healthcare facilities use
telephone surveys to follow up with patients a week after the service was pro-
vided rather than having them complete a written survey at the time of the
service. More recently, healthcare organizations have started sending patients e-
mails with hot links to an Internet survey as a less expensive and less intrusive
substitute for telephone surveys.
Although telephone interviews or Web surveys eliminate the inconvenience of
gathering information while patients are still in the healthcare facility, they present
other challenges. Survey methods rely on retrospective information that can be
blurred by the passage of time. If the service received was too brief or insignicant
for patients to recall accurately, or if patients have no special motivation to partici-
pate, the information they provide is likely to be unreliable or incomplete.
In addition, in this age of intense e-mail and telephone solicitations, custom-
ers often regard telephone and Web-based surveys as intrusions on their time and
violations of their privacy. Annoyed respondents feeling resentment toward the
organization for calling them at home are likely to bias the data.
Red Lobster and Steak & Ale avoid some of these difculties by building into
their customer meal-checks system a code that prints an 800 telephone number for
every nth customer to call; the automated response system then asks customers to
press touchtone buttons to answer questions about their experience at the restau-
rant. In return for participation, the restaurant offers coupons for free desserts or
two entrees for the price of one on the customers next visit. Healthcare providers
can adopt this strategy by inviting patients to participate in a survey. Participants
names are then entered into a rafe to win health-related enticements such as free
family passes to a gym or multiplex.
Because telephone interviews conducted by a trained interviewer are expensive,
Web-based surveys are preferred. When data analysis and expert interpretation are
included, the total cost for a statistically valid telephone survey can be high, whereas
many Web-based tools offer automatic data analysis and are far less expensive.
354 Achieving Service Excellence
Mystery Shoppers
Mystery shoppers provide management with an objective snapshot of the health-
care experience. While posing as patients, these trained observers methodically
sample the service and its delivery, take note of the environment, and then compile
a systematic and detailed report of their experience. They can sample the admis-
sions process or an overnight stay at a hospital or a routine checkup at a freestand-
ing clinic.
Mystery shopper reports generally include numerical ratings of many aspects
of an experience. These ratings then allow organizations to compare results before
and after an improvement is instituted. Mystery shoppers may also be directed to
observe competitors in the market, gathering information about the competitions
quality level, program/service offerings, facilities, staff performance, and prices.
Organizations may hire a commercial service, a consultant, an actor, or even a staff
member to conduct a mystery-shopper visit (Buckley and Larkin 2007).
Generally, employees know that their organization uses mystery shoppers, but
they do not know who the shoppers are or when they will appear. Because these
visits are unannounced, employees cannot prepare or dress up their performance.
Shoppers can be instructed to show up at random times during various shifts to
assess differences in quality and value on different oors, conditions, employees,
and managers (Van der Wiele, Hesselink, and van Iwaarden 2005).
One of the most important benets of a mystery shopper program is that it pro-
duces information that can assist managers in identifying performance decien-
cies that call for employee coaching. Employees may discount or feel antagonistic
and defensive about supervisory feedback, making them reluctant to express their
need for coaching or to follow through on manager-recommended improvements.
Mystery-shopper observations spell out these needs, enabling the manager to use
the customers voice to coach employees.
An article in the Wall Street Journal reports that mystery shoppers in healthcare
may make various inquiries over the phone, go to a doctors ofce or an emergency
department for a checkup, or even fake symptoms (Wang 2006). Generally, they
pose as uninsured patients. Mystery patient reports lead to improvements, ranging
from placing signage throughout the facility to training staff to empathize better
with patients.
Mystery shoppers test the staff s ability to respond to anticipated service prob-
lems and service delivery failures. For example, shoppers can create a problem or
intensify a situation by asking certain questions or requesting unique services to as-
sess employee responses under pressure. The Wall Street Journal article reports one
shoppers experience when she asked for an extra pillow: The nurse told her to send
Chapter 13: Measuring the Quality of the Healthcare Experience 355
her husband to the dollar store to buy one. Mystery shoppers can also gauge the
effectiveness of a particular training program by shopping at a healthcare organiza-
tion before and after the training (Wang 2006).
The main disadvantage of a mystery shopper is the small size of the sample from
which the shopper generates reports. Because anyone can have a bad day or a bad
shift, a mystery shopper may base conclusions on unusual or atypical experiences.
One or two observations are not a statistically valid sample of anything, but hiring
enough mystery shoppers to yield a valid sample is impractical and expensive.
Further, the unique preferences, biases, or expectations of individual shoppers
can unduly inuence a report. Well-trained shoppers with specic information
about the organizations service standards, instructions on what to observe, and
guidelines for evaluating the experience avoid this pitfall.
However, a healthcare mystery shopper can only sample so many aspects of the
healthcare experience. A mystery shopper cannot go through a surgical procedure,
for example. Two other negatives are that the staff are spending time on a patient
who is not really in need of medical service and that seeking treatment that is not
needed may be unethical.
PUBLI C METRI CS
One of the fastest-growing trends in measuring patient quality are those metrics
provided by governmental or external organizations. For example, the University
of Michigans American Customer Satisfaction Index (ACSI) includes several cat-
egories for healthcare. Interestingly, of the services ACSI measures, ambulatory
care scores the highest, with an 81 rating out of a possible 100. In Great Britain,
the National Health Commission publishes an assessment of healthcare providers
that uses patient assessment of their satisfaction for nearly 10 percent of the total
score.
As mentioned in Chapter 10, many websites can help healthcare consumers
gauge the service quality of hospitals, nursing homes, long-term care providers,
and other organizations; see, for example, www.hospitalcompare.hhs.gov or www.
leapfroggroup.org. Consumer Reports rates the service quality of hospitals by state,
assessing aspects as how well doctors communicate and how attentive the staff are.
Magazines, such as U.S. News and World Report, rank healthcare organizations on
the basis of customer feedback and reported clinical outcomes.
Finally, many regional and state organizations and governments collect and
make available data on various healthcare providers, from hospitals to long-
term care and nursing home facilities to individual physicians. The point is
356 Achieving Service Excellence
that a wide variety of metrics can be used, and healthcare managers should be
aware of those that can provide feedback metrics to staff and serve as bench-
marks against which the organizations performance levels can be consistently
and accurately assessed.
DETERMI NI NG THE MEASURE THAT FI TS
What gets measured gets managed and hopefully improved, but determining which
measure is most appropriate to use is another challenge. A major hospital in a for-
prot chain, for example, may require more elaborate and expensive strategies to
measure feedback because poor service can harm the reputation and bottom line
of the hospital, the chain with which the hospital is afliated, and the livelihood of
countless employees up and down the line.
The value to this hospital of nding and correcting service problems so that
it can deliver the healthcare quality its patients expect is tremendous. Failing to
meet patient expectations will quickly make it and everything afliated with it
uncompetitive in a dynamic marketplace. On the other hand, the ofce of a small
independent physician who has a well-established reputation for providing superb
clinical treatment in a caring manner may learn just as much from asking patients
about their experience without incurring the expense of sophisticated quality as-
sessment methods.
Costs and level of expertise used to gather data vary also. An important ques-
tion to ask is who should collect data: employees, consultants, or a professional
survey research organization. Using staff members is the least expensive alternative,
but they also have the least expertise in customer service research and may lack the
communication skills to interview effectively. Consultants and survey organiza-
tions cost more, but they are better able to gather and interpret more detailed,
sophisticated statistical data using more sophisticated techniques. For example,
employee surveyors cannot measure eye-pupil dilation, but professionals can.
Regardless of the evaluation technique selected to measure healthcare quality,
one thing is certain: Patients evaluate service every time it is delivered, and they
form distinct opinions about its quality and value. All healthcare organizations that
aspire to excellence must constantly assess the quality of their healthcare experience
through their patients eyes. Most patients and their families are happy to tell what
they thought about their experience if they are asked in the right way at the right
time. Telephone surveyors calling on Friday night during dinner time will get the
turndown they deserve, but a comment card left in a patient room to be turned
Chapter 13: Measuring the Quality of the Healthcare Experience 357
in upon discharge will get far better attention. Healthcare managers striving for
excellence need to ask the right questions at the right time, of the right mix of pa-
tients, to obtain the information necessary to ensure service that meets and exceeds
patient expectations.
Irrespective of whether qualitative or quantitative assessment methods are used
or which particular methods are used alone or in combination, follow-up is crucial.
If internal or external customers provide data to organizations that they perceive to
be unresponsive to their input, the quantity and quality of future input will be lim-
ited. Why provide new data if old data are ignored? Not collecting customer infor-
mation is better than collecting and ignoring the information. Follow-up should
include communicating to staff clear and accurate economic measures of loss from
the defection of one customer, setting service standards based on customer expecta-
tions, eliminating substandard performance and performers, and communicating
with both patients and staff about how their input has led to service improvements
(Albrecht and Zemke 2002).
CONCLUSI ON
Numerous methods are available for measuring the degree to which service excel-
lence is achieved. Each healthcare organization needs to assess which methods will
work best for its own situation. Each organization also needs to determine whether
to gather data using its own resources or contract the function to an outside group.
The degree of sophistication required and the organizations internal resources will
drive this decision.
Regardless of whether the organization uses qualitative or quantitative measures
(or both) or internal or external resources to generate the data, the purpose of col-
lecting data on service quality should be to enhance customer service. Once base-
line information is established, the organization can focus on setting performance
standards for a few critical areas at a time and spend several months achieving
service excellence. Staff will not be overwhelmed, managers will be able to monitor
a manageable number of critical areas, and everyone will be able to learn together
and support each other in the process. Once the original areas are improved, the
organization can take on additional areas.
A major challenge is how to achieve and maintain continuous improvement.
One approach is to celebrate individual and group success in achieving service ex-
cellence. Staff need and want to be appreciated for their achievements and contribu-
tions. Among the more successful celebration methods are mentions in newsletters,
358 Achieving Service Excellence
posting positive letters about employees on bulletin boards, sharing stories of excel-
lent service at staff meetings, and sending thank you notes. Every meeting should
be viewed as an opportunity to teach, positively reinforce, and celebrate successes
in achieving customer satisfaction. This process should be continuous.
Service Strategies
1. Focus on the quality and outcomes of both clinical service and customer
service.
2. Be aware that if you do not measure it, you cannot manage it; if you do
not manage it, you cannot improve it.
3. Use the best combination of qualitative and quantitative methods to
measure customer satisfaction.
4. Balance the value of service information obtained from patients with the
cost of obtaining it.
5. Recognize the strengths and weaknesses of the available assessment
techniques.
6. Offer service guarantees.
7. Assess the quality of service for both internal and external customers.
8. Follow up on implementation of service improvement ideas generated
from all quality assessment methods.
9. Get better or get beaten in the competitive healthcare marketplace.
10. Maintain momentum for customer service by continually using positive
reinforcement and celebrating successes.
359
Those who enter to buy, support me. Those who come to atter, please me.
Those who complain, teach how I may please others so that more will come.
Only those hurt me who are displeased but do not complain.
Marshall Field, department store magnate
C H A P T E R 1 4
Fixing Healthcare Service Failures
Service Principle:
Eliminate all sources of disappointment positively and quickly
Every customer assumes that the service she pays for will, at the least, meet
her expectations. For example, a patient who makes an appointment for a lab test
expects the appointment will be kept when she arrives and the test will be done
properly. If the initial expectations are met, the patient is satised. If the initial
expectations are exceeded, the patient is delighted and willing to return when the
need arises. Exceeding patient expectations creates apostles and evangelists
happy customers who spread positive word of mouth to their family, friends, and
associates about the excellent total healthcare experience they received. Such favor-
able words reinforce the provider organizations public image and reputation.
What happens, however, if the patients initial expectations go unmet? For
example, when the patient arrives for his scheduled appointment, the reception-
ist informs him that he needs to reschedule because the doctor cancelled her ap-
pointments for the day or a machine or equipment is malfunctioning. This pa-
tient will feel dissatised at best, and at worst, the patient will turn into an angry
avengeran unhappy customer who bad-mouths the organization to family,
friends, and anyone else who will listen. A typical dissatised patient may tell eight
to ten people about the problem he encountered, but an avenger will likely create
a website to share his disappointment with millions of people.
Service failures, like clinical errors, are inevitable. Many healthcare organiza-
tions do plan well for clinical problems, but they do not anticipate service prob-
lems with the same care. They incorrectly assume or hope that the service will be
available as promised, the setting and delivery system will function as designed,
and the staff will perform as they were trainedconsistently, every time.
360 Achieving Service Excellence
Well-managed organizations, however, work hard to identify, plan for, and pre-
vent all types of service failures, and they understand that these problems vary in
frequency, timing, and severity. Not meeting patient expectations can occur any
time during a single healthcare experience or across multiple experiences with the
same organization. Because rst impressions are so important, a problem that takes
place early in the process will weigh more heavily on the patients mind than a
problem that occurs later. Big errors count more than little ones.
Customers have more tolerance for poor service than for poor service recovery
(Michel, Bowen, and Johnston 2008). If a customer experiences a second fail-
ure of the same service, no recovery strategy can work well; in all likelihood, that
customer will be lost forever. Furthermore, Michel, Bowen, and Johnston (2008)
suggest that a customer is most annoyed and angered not by her dissatisfaction
with the service but by her belief that the system that caused the failure remains
unchanged and thus will lead to more failure. In other words, customers are turned
off by an organization that is so indifferent to its service quality that it does not
make the effort to learn from its mistakes.
Learning from failures is more important than simply xing problems because
learning results in process improvements. Improvements, in turn, have a direct
impact on the bottom line, as they reduce costs of service errors, boost employee
efciency and morale, and increase customer satisfaction. Although many hospitals
have instituted procedures for handling patient complaints in response to accredi-
tation requirements, they do not formally track or capture complaints for learning
and improvement purposes (Donnelly and Strife 2006).
In this chapter, we address the following:
The importance of fnding and fxing service failures
The reasons such failures occur
Strategies for service recovery and service failure prevention
Ultimately, if the organization neglects to respond to a service problem, it fails
twice, not once: First, it did not meet the most basic customer expectation; second,
it did not resolve, quickly and appropriately, the problem caused by the rst.
ELEMENTS OF A SERVI CE FAI LURE
Despite the best-laid plans, service failure is a reality in all organizations. Complex
organizations function as a system, with interdependent and tightly intertwined
parts. One mistake in one part will affect the rest of the system, and the tighter the
Chapter 14: Fixing Healthcare Service Failures 361
intertwining of these parts, the more susceptible the whole system is to disaster.
The difference between an excellent and a poor service organization, however, is
that the best one works hard not only to remedy failures but also to prevent them
from occurring at all. Service failures occur for two reasons: human error and sys-
tem error, which are discussed in the following section.
Sources
Providers can fall short of a patients expectations at any point in the healthcare
experience. The product, setting, or delivery system may be inadequate or inap-
propriate, or the staff may perform or behave poorly.
For example, if the patients teeth do not look as white as she expected when she
walks out of the dentists ofce, she will be dissatised and a service failure could
result. Similarly, if the patients lab test takes several hours to complete, instead of
the one-hour time frame he was promised, he will deem the experience a failure.
The environment or setting can also cause service failures. If the patient thinks the
ambient temperature is too cold, the smell of antiseptic too strong, the exam or
waiting rooms too dirty, or the parking lot too dark and too far away, she will feel
unhappy about these failures. Certainly, staff can bring about service failures if they
are unfriendly or rude, poorly trained or inexperienced, and not forthcoming with
information or misinformed. The service product, setting, delivery system, and
staff must be carefully managed to minimize the likelihood of a service failure.
Magid and colleagues (2009) illustrate some organizations failure in managing
their services. These researchers surveyed 3,562 emergency medicine clinicians in
65 hospitals. The majority of the respondents said their emergency department
(ED) lacks sufcient space in which to deliver patient care, and one-third said the
number of patients who presented in the ED consistently exceeds their capacity
to provide safe care. On the stafng front, two-thirds reported that the number
of nursing staff is insufcient to handle patient loads during busy periods, and 40
percent said they do not have enough doctors to handle patient loads when the ED
gets busy.
Taylor, Wolfe, and Cameron (2002) looked at the same ED issues but from
the patient perspective. These researchers found 1,141 problems were related to
patient treatment, including inadequate treatment and diagnosis; 1,079 prob-
lems were related to communication, including poor staff attitude, discourtesy,
and rudeness; and 407 problems related to delay in treatment (Taylor, Wolfe, and
Cameron 2002).
362 Achieving Service Excellence
Patients Role
Service failures come in different degrees, ranging from catastrophies (which
make the newspaper headlines) to minor slipups (which happen behind the
scenes and patients never know about). Along this continuum are an infinite
number of mistakes. Because the patient defines the quality of the service
experience, the patient also defines the nature and severity of each service fail-
ure. Two patients dissatisfied about the same failure can have different degrees
of unhappinessone can be very unhappy, while the other can be mildly
unhappy.
Sometimes, the organizations product, setting, delivery system, or staff
may not be the cause of the disappointment; the patient may be at the root of
the problem. For example, a plastic surgeon performs a facelift as expected and
requested by the patient, but the patient may still deem the operation a failure
simply because she does not like the way her new face looks. The patient who
ignores warning signs or fills out forms incorrectly also contributes to service
failures. Other examples include patients who act belligerently toward staff
and other patients and those who sabotage their own care by refusing to take
their medication or follow their doctors orders. These service failures are not
initiated by the organization and are often beyond its capability to manage,
but the organization must still anticipate, address, and prevent them as well
as possible.
It is human nature to attribute successes to ourselves and problems to oth-
ers. Thus, patients often point their ngers at someone else when a service
failure occurs. Organizations that want to keep patient-caused problems from
destroying the patients healthcare experience and his feeling of goodwill to-
ward the enterprise develop and use certain strategies (such as the following)
designed to help the patient recover from the failures he created without mak-
ing him feel foolish or blamed:
Distribute a heart-healthy or calorie-restricted menu to patients who refuse
to abide by dietary orders.
Provide clear, simple care instructions to family members about the patients
care.
Offer assistance with flling out forms.
Make warning and directional signs bigger, bolder, and in languages
understood by the primary service population (e.g., English, Spanish,
Chinese, Polish, Arabic).
Chapter 14: Fixing Healthcare Service Failures 363
Customer Defection
Patients want an active, interested, positive attitude from their providers. They will
not buy into television, print, Internet, or billboard ads that tout the excellence of
an organization if they have experienced the opposite.
Customer defectionleaving one provider for anothercan be prevented by
ensuring that the total healthcare experience is excellent in the rst place and, if a
service failure occurs, by immediately putting a solid service recovery plan to work.
According to Reichheld and Sasser (1990), just a 5 percent reduction in customer
defection rate can raise prots by 25 to 85 percent. Clark and Malone (2005) sug-
gest a similar increase in prots and customer retention as a result of successfully
addressing customer complaints.
Usually, a service recovery effort yields one of three outcomes:
1. The problem is xed, and the formerly unhappy patient is now happy.
2. The problem is not xed, and the formerly unhappy patient remains unhappy.
3. The problem is xed but not satisfactorily or completely, and the formerly
unhappy patient has made concessions with the organization and is now
neutralneither happy nor unhappy.
As described earlier, happy patients may become apostles or evangelists,
while unhappy patients may turn into avengers. Neutral patients, on the other
hand, may forget the whole experience and, as a result, the organization as well.
In extreme cases, such as medical catastrophes, neutralizing the unhappy pa-
tient may be the best outcome the organization can reach. For example, if a patient
develops an infection after a successful operation, all the organization can do to
neutralize the patients level of dissatisfaction is to ensure that all aspects of the
hospitalization is as patient-centered and error-free as humanly possible. Here, the
goal is to somehow offset the adverse event with service excellence. Even if that
goal is achieved, the patient will still leave feeling neutral and will likely defect to
another provider the next time around.
Furthermore, neutral customers are inuenced by other factors. A recent study
of insurance providers indicates that a patients switching behavior (or customer
defection) is primarily a function of three factors (QMS Partners 2009):
1. Name recognition or lack thereof
2. Stability of the provider
3. Efciency with which billing complaints are handled
364 Achieving Service Excellence
The third factor implies that healthcare consumers highly value the way they are
treated by the organizations employees. A service failure in the people part of the
healthcare experience can make the difference between customer loyalty and cus-
tomer defection.
The Impact of Evangelists and Avengers
According to Sherman and Sherman (1998), 1 avenger tells his unfortunate expe-
rience to at least 12 people. Each of those 12 then shares the story to 5 or more
people. On average, an avenger has an audience of about 72 people. Furthermore,
if 8 avengers each spreads the disappointing news to 12 others, each of whom in
turn tells 5 of their associates, then 576 people hear the negative word of mouth
that only 8 patients actually experienced. A simpler calculation is this: Each dissat-
ised customer sends out, verbally or in writing, about 70 negative messages.
Conversely, evangelists do not talk about their positive experience as widely as
avengers do. Evangelists share their good stories to approximately 6 other people
(Hart, Heskett, and Sasser 1990).
DI SSATI SFI ED CUSTOMER S RESPONSES
Unhappy patients react in one or a combination of three ways: never return, com-
plain, and bad-mouth the organization.
Never Return
A dissatised patient vows to never return to the same provider. This is the worst
customer reaction for an organization because it also means the angry patient will
tell others about the negative experience. In this situation, the organization loses
not only the current business of this patient but also the future business of all the
people the patient can inuence. Service recovery should be especially focused on
this group of unhappy customers.
Complain
Benchmark organizations encourage patients and other customers to complain,
and they thank them for it. A complaint should be viewed as an opportunity, not
Chapter 14: Fixing Healthcare Service Failures 365
a challenge, because it gives the organization a chance to rene the system and
make customers happy. Patients who complain either verbally or in writing allow
employees and managers to x the problem before the problem and the dissatisfac-
tion are shared with others.
Organizations may also teach patients to complain, if necessary, as detailed
complaints function as feedback that can be measured and monitored over time.
Complaining patients are less likely to defect to another provider and to bad-
mouth the organization than those who do not express their dissatisfaction to the
organization. Making sure no customer leaves unhappy is obviously advantageous
to any organization. The best way to ensure this is to seek out patient complaints
before they leave the hospital, clinic, or ofce.
The results of a landmark study conducted by the Technical Assistance Research
Program (TARP 1986) for the U.S. Ofce of Consumer Affairs strongly suggested
that customers who complain are more loyal than those who do not and that hav-
ing complaints satisfactorily resolved increased the customers brand loyalty. These
customers were happier with the organization after experiencing bad service than
before because the dissatisfaction led to improvement. Research conducted on the
relationship between customer loyalty and complaints since this TARP study has
conrmed these ndings from more than two decades ago.
Bad-Mouth the Organization
If the negative experience is costlynancially and/or personallythe patient is
more likely to spread the bad word. The greater the cost to the patient, the greater
the motivation to tell. People who hear such negative stories will be discouraged to
patronize the same provider, if given a choice.
Angry customers (avengers) who used to be limited to writing letters to corpo-
rate headquarters or the Better Business Bureau, putting up signs in their yard, or
painting lemon on the car now have a more powerful tool: the Internet. For a
minimal fee, anyone with Internet access can create a website or a blog to tell the
world about an offending company and also invite others to share their stories of
poor treatment. In this day of instant and global communication, a bad-mouther
can spread the message to millions of people; the same is true of evangelists.
Word of mouth is important for several reasons. Friends, family, colleagues,
and other associates tend to be more credible sources than impersonal testimonials
(Lake 2009). When a friend reports that a certain physician is cold and uncaring,
you no longer believe or are at least wary of the advertisements that promote the
366 Achieving Service Excellence
warm and personal touch of that physician. Personal accounts, either good or
bad, from friends and family are also more vivid, more convincing, and more com-
pelling than any paid commercial advertising.
Dollar Value of Customer Dissatisfaction
Customer defection and negative word of mouth create an expensive problem for
the organization. Over time, the loss of revenue from a patient who opts never to
return and from potential customers who listened to the unhappy patients bad-
mouthing is tremendous. Because that dollar value is so high, hardly any effort to
x a service failure is too extreme.
Consider these numbers that illustrate the point. Suppose the average person is
admitted into the hospital three times over her lifetime, and the average hospital
bill for one stay is $15,000. For Patient A, who vowed never to return to and has
bad-mouthed the hospital, the lifetime revenue loss sustained by the hospital is
$45,000. If Patient A is married and has two children, the lifetime family revenue
loss rises to $180,000. If the bad-mouthing damage is calculated (Patient A tells 12
others, according to calculations by Sherman and Sherman [1998]), the lifetime
loss could reach $540,000 ($45,000 12) at a minimum.
A similar type of calculation can be done for a managed care organization that
lost a multiyear contract with one dissatised employer that represents 300 covered
lives. Lets assume annual premiums of $3,000 per enrollee over a ve-year con-
tract. The cost of this loss is $4.5 million (300 $15,000 = $4.5 million). Simi-
larly, a physicians defection from a hospital, assuming he brought in 2 admissions
per week for 45 weeks a year, will result in a $1.35 million loss (90 $15,000 =
$1.35 million).
To make these gures meaningful to employees, the nancial loss can be calcu-
lated at the department levelthat is, what dollar amount is associated with the
defection of one nurse? Such calculations can also lead to some surprisingly large
numbers for even a small business. To show how a dentist might come up with
numbers like these, assume that the dentists satised patients come in for treat-
ment twice a year and spend an average of $150 each time. The total value of each
satised biannual patients business for the next ve years is $1,500. Conversely,
positive word of mouth from happy patients can bring in enormous numbers in
potential revenues.
The point of this exercise is simple: The long-term cost of patient defection
and negative word of mouth is usually much more than the expense of correcting
a service failureimmediately and appropriately.
Chapter 14: Fixing Healthcare Service Failures 367
SERVI CE RECOVERY
An organizations attempt at service recovery can make a positive or negative im-
pression on the patient who experienced a service failure (Berry 2009). A small
problem can turn big if the effort is half-hearted, misguided, or too little too late. A
big problem minimized or eliminated, on the other hand, becomes a great example
of customer service that must be shared with the rest of the organization.
In addition, the way an organization responds to complaints and service fail-
ures, whether well or poorly, communicates how committed it is to patient satisfac-
tion. Similarly, the way an organization seeks complaints and service failures sends
a loud message about what it truly believes in. Compare the following hypothetical
organizations.
Hospital A is defensive about patient complaints and keeps them secret (al-
though employees usually hear about them anyway), resolves problems as cheaply
and quietly as possible, and seeks people to blame for the complaints. Hospital B,
on the other hand, aggressively looks for and xes service failures, disseminates nd-
ings about complaints and failures throughout the organization, makes quick and
fair adjustments and improvements, and seeks solutions rather than scapegoats.
Which of the two organizations provides better customer service?
Some companies claim strong nancial benets from successful complaint reso-
lution. According to Sherman and Sherman (1998), even if a service failure occurs,
about 70 percent of the patients affected will continue to do business with the pro-
vider if their issues are resolved eventually; that percentage jumps up to 95 if the is-
sues are resolved on the spot. This nding translates into large sums of money over
the lifetime of these patients and their families and friends. Such data motivate
benchmark healthcare organizations to engage their frontline employees in han-
dling service complaints and problems. These organizations empower employees
to address the failures quickly and in whatever way they see t, without manager
authorization or approval. Hart, Heskett, and Sasser (1990) agree: The surest way
to recover from service mishaps is for workers on the front line to identify and solve
the customers problem.
Complaints and Other Service Failure Data
Most organizations generally obtain and study only a fraction of the service failure
data collected from customers, employees, and managers. Even when managers
agree that customer feedback is essential, often that information does not ow
from the division that gathers and addresses it into the rest of the organization
368 Achieving Service Excellence
(Michel, Bowen, and Johnston 2008). Also, most rms fail to document and
categorize complaints adequately, which makes it more difcult to learn from
mistakes (Tax and Brown 1998).
Research indicates that the more negative feedback a customer service depart-
ment collects, the more isolated that department becomes because it does not want
to be seen as a source of friction. Some service recovery units soak up customer
complaints and problems with no expectation of feeding this information back to
the organization. Other organizations actually impede service recovery by reward-
ing low complaint rates and then assuming that a decline in the number of com-
plaints signies an improvement in customer satisfaction.
Employee attitudes (positive or negative) about management spill over to the
way they treat patients and other customers. Positive attitudes result when em-
ployees believe that management provides them with the means and the support
to handle service failures. When employees believe otherwise, they tend to think
they are being treated unfairly and display passive and maladaptive behaviors that
can sabotage customer service. At organizations that reward low complaint rates
or punish/blame employees for service failures, employees may send dissatised
customers away instead of keeping them by apologizing and addressing the issue,
which employees most likely created.
SERVI CE RECOVERY STRATEGI ES
Berry (2009) argues that the organization should always apologize for service fail-
ures, but an apology alone is seldom sufcient. Three major strategies are available
for dealing with service failures:
1. Proactive or preventive strategies for identifying problems before they happen;
these strategies are built into the design of the service, employee training, and
the delivery system
2. Process strategies for monitoring the critical moments of the service delivery
3. Outcome strategies for seeking out problems after the service experience has
happened
Preventive Strategies
Preventing problems is easier and less costly than recovering from them. Proactive
strategies are designed to identify and x any trouble spots before they become a
service failure.
Chapter 14: Fixing Healthcare Service Failures 369
Forecasting and Managing Demand
If a statistical prediction of patient demand on a particular day indicates that the
hospital will be full, then a preventive strategy is to schedule full staff on each shift,
make extra supplies available, and prepare departments for full capacity. The same
strategies could work for a physician practice that is anticipating a lot of patient
visits on a given day. An appointment system may help manage the expectation of
patients, and sufcient staff and supplies can be made available.
If the organization plans poorly, and patients have to wait longer than they feel
is appropriate, their perception of the overall quality of their service experience
declines rapidly, and a service failure results. Keeping the wait time short avoids
this type of failure.
If demand can be forecasted for a longer period, then other proactive strategies
can be implemented. For example, if demand in two years is expected to increase
by 20 percent, new capacity should be built, new employees should be hired and
trained, and inventories should be increased to prevent the occurrence of long
waits, unavailable supplies, or insufcient and untrained staff. Even if major steps
(hiring more staff, building new capacity) cannot be taken because of limited re-
sources, employees may be trained to cope with demand surges. Just as hospitals
run disaster drills with re-and-rescue teams, so too can hospitals and clinics train
their healthcare workers and give them practice exercises to handle unexpected
increases in demand.
Quality Teams, Training, and Simulation
The popular use of quality teams is another preventive strategy. Get staff who are
directly involved in the service experience together, and ask them to identify prob-
lems they have seen or heard about and to suggest strategies for preventing those
problems. Adequate training of frontline employees before they even begin to serve
patients is also a preventive measure. Any highly reliable organization ensures that
its frontline staff know exactly what customers need, want, and expect from the
total experience and are motivated to do whatever it takes to meet (at a minimum)
and exceed those customer factors, every time.
Another preventive/proactive approach is to use analytical models, such as those
discussed in chapters 11 and 12, to simulate all or part of the delivery system or the
service recovery process. Once a model is created that represents a wide variety of
patientprovider interactions, the manager and staff can analyze each situation to
determine areas of service failures. On a simpler level, role playing and structured
scenario simulations can help employees evaluate all types of service problems and
learn effective recovery strategies.
Michel, Bowen, and Johnston (2008) suggest creating and communicating a
service logic that explains how everything ts together. This should be a kind of
370 Achieving Service Excellence
mission statement or a summary of how and why the business provides its services.
It should integrate the perspectives of all three groupscustomers, employees, and
managers:
What is the customer trying to accomplish and why?
How is the service produced and why?
What are employees doing to provide the service and why?
This statement should include a detailed study of internal operations, map out
how the organization responds to customer complaints, and describe how that in-
formation is used to improve the service recovery process. Similar mapping should
detail every step of customer experiences, highlighting customer thoughts, reac-
tions, and emotions.
Performance Standards
Performance standards are tools that not only help employees do their job during
the service experience but also guide employees and the organization in evaluating
the performance afterward. Employees and their managers can also use these stan-
dards to monitor how well or poorly they have performed over time.
Some standards are purely preventive because they can be met before patients
enter the door. For example, if a clinic can reliably predict the number of patients
who will come in on a given day of the week, that forecast can be used as a basis or
standard for the quantity of medical supplies to prepare and order. If the predic-
tion is correct, the service failure of not having enough supplies on hand should
not occur.
Other preventive performance standards should be set for the following:
Number of training hours required for staff annually
Number of equipment to be purchased
Number of examining tables to be set up
Level of supply inventory
Performance standards also help patients understand the level of service they
can expect. Examples of such standards include We will try to resolve problems of
types A, B, and C within two hours, We will try to resolve problems of types D,
E, and F within one week, or If you leave a message on our help-desk voicemail,
we will call you back within one hour.
Many customers of the Ritz-Carlton Hotel know, for example, that phone calls
are supposed to be answered within three rings and that after a customer registers
Chapter 14: Fixing Healthcare Service Failures 371
a complaint, a Ritz employee is supposed to make a follow-up call within 20 min-
utes. Similarly, hospital nurses in many facilities are aware that the patient call bell
is supposed to be answered within 30 seconds.
JetBlue provides an excellent example of service recovery reinforced by a service
guarantee. After snowstorms left some JetBlue customers stranded for many hours
on planes that were not equipped to provide food, water, and other creature com-
forts, JetBlue engaged its customers in a dialogue about what went wrong and how
the airline might x it. The CEO also instituted a service guarantee to indicate the
service standards it would implement in the future and the steps it was taking to
support that guarantee (Lane 2007). As a result, most JetBlue customers continue
to patronize the airline.
Poka-Yokes
To avoid wrong-side surgery, sometimes called bilateral confusion or symmetry
failure, the National Academy of Orthopedic Surgeons has urged its physician
members to sign their names on the spot to be cut. Surgical patients often write in
felt-tipped marker I hurt here with an arrow pointing to an elbow or yes on one
knee and no on the other. These doctors and patients, probably without knowing
the term, are using poka-yokes.
The poka-yoke is a proactive strategy that aims to keep service as awless as
possible. Conceived by the late Shigeo Shingo, an industrial engineer at Toyota
and a quality improvement leader in Japan, poka-yoke makes service quality easy
to deliver and service problems difcult to incur because it requires the inspection
of the system for possible problems and the development of simple means to pre-
vent or point out those mistakes. For example, a surgeons tray and a mechanics
wrench-set box often have a unique indentation for each item to ensure that no
instrument is left in a patient or no wrench is left in an engine. Another example
is the identication bands hospitals use to ensure that the right patient gets the
right treatment. Shingo called these problem-preventing devices or procedures
poka-yokes (POH-kah-YOH-kay), which means mistake proong or avoid
mistakes in Japanese.
Shingo distinguished three types of inspection:
1. Successive inspection, where the next person checks the quality and accuracy
of the previous persons work
2. Self-inspection, where people check their own work
3. Source inspection, where potential mistakes are located at their source and
xed before they can become service errors. Poka-yokes are used mainly to
prevent source mistakes.
372 Achieving Service Excellence
An example of successive inspection is when an orderly checks a patients chart
to ensure that it corresponds with the instruction about where the patient should
be transported. An example of self-inspection is when an attending nurse com-
pares the prepared drug against the patients chart before administering the drug.
An example of source inspection is when a surgical nurse examines the prepared
medical supplies (e.g., surgical tools, bandages) to ensure that sufcient kinds and
quantities of the items are available.
Poka-yokes are either warnings that signal the existence of a problem or con-
trols that stop production until the problem is resolved (Chase and Stuart 1994).
A warning poka-yoke could be a light that ashes when a patients blood pressure is
too low, signaling the nurse to adjust the drip before the patient goes into shock. A
control poka-yoke could be a device that turns an x-ray machine off whenever the
roentgen level is too high. Warning and control poka-yokes can be further divided
into three types: contact, xed values, and motion step.
Contact poka-yokes monitor an items physical characteristics to determine if it
is right or meets a predened specication. Some pharmacies, for example, prepare
standard quantities of drugs to ensure the dosage is correct before the medicine is
distributed. Fixed-values poka-yokes deal with established quantities. For example,
surgical teams use prepackaged surgical supplies so that they know exactly how
many bandages, surgical tools, and so forth are available for use. When the surgery
is completed, the team can count every item to make sure nothing has been left in
the patient. Motion-step poka-yokes are useful in processes where one error-prone
step must be completed correctly before the next step can take place. A simple ex-
ample is the start button on the x-ray machine. The button is outside the exposure
area so that technicians cannot take the x-ray until they leave the room and are
protected.
All poka-yokes should be simple, easy to use, and inexpensive. Something can
go wrong at any point in service delivery, and the poka-yoke method encourages
managers to think rst about what might go wrong.
Process Strategies
Process strategies for nding service failures monitor the delivery while it is taking
place. The idea is to design mechanisms into the delivery system that will catch and
x problems before they affect the quality of the healthcare experience; blood pressure
and heart monitors are examples of such mechanisms. The advantage of process con-
trols is that they can catch errors as they happen, enabling immediate correction.
Chapter 14: Fixing Healthcare Service Failures 373
Process performance standards provide employees with objective measures
with which to monitor their own performance while they are doing their job.
One example is specifying how long a patient has to wait in the emergency de-
partment before receiving attention. Other illustrations include the number of
times per hour that a nurse must check on an intensive care patient or the number
of patients waiting for service before a cross-trained staff member steps in to re-
duce the waiting time at peak demand. These are all process-related measures that
allow the staff to minimize errors or catch them while the healthcare experience
is underway.
An important part of any process strategy is to get unhappy patients to com-
plain during the healthcare experience. This is a more difcult challenge than one
might think: Although some patients are comfortable with complaining, most are
not. Most patients are either unwilling to take the time, believe no one cares or
will do anything about their complaints, or are too angry or too disappointed to
say anything.
Research on complaint behavior has identied strategies for encouraging pa-
tients to complain (Michel, Bowen, and Johnston 2008):
Solicit complaints. Because many service failures are caused by provider
errors, all personnel should be trained to solicit complaints about their own
performance. This is not an easy task for providers, as they may see mistakes
are punished while catching errors is rewarded, and most people do not want
to admit their mistakes or feel criticized for them. Thus, the organization
must design a complaint strategy that accommodates its staff s perception
about complaints.
Read a patients body language for clues on her dissatisfaction. This observation
can yield information that might otherwise go unmentioned. Frontline staff or
direct caregivers should be trained to watch and recognize body language and
to be receptive and sympathetic once the complaints are verbalized. Patients
must perceive these employees as being interested and concerned about their
well-being and opinions. Otherwise, patients will feel wary and will choose
not to say anything.
Empower staff. Provide employees with the freedom to address complaints and
service failures on their own, as much as the organizations business strategy
allows. Autonomy encourages staff to do what is right for the customer, and
that prevents service failures from happening in the rst place. For example,
Ritz-Carlton authorizes front-desk personnel to credit unhappy customers up
to $2,000 without asking approval from a supervisor.
374 Achieving Service Excellence
Outcome Strategies
Outcome strategies identify service problems after they have occurred so that prob-
lems can be xed and future problems can be prevented. The most basic outcome
strategy is simply to ask the patient, How is everything going today? Other more
systematic illustrations include (1) providing toll-free or 800 phone numbers for
use by former patients who want to report their dissatisfaction and (2) asking pa-
tients to ll out a brief questionnaire when they pay their bills.
Organizations must make unequivocally clear to patients that they care to know
about any service failures that patients have encountered. What inuences a pa-
tients decision to seek redress for a problem or to let it go is her perception of
whether the organization will do something about it. Even patients who are re-
luctant to complain are more likely to do so if they think something will be done
about the problem (Davidson 2007). Customers often do not want a payoff; they
simply want a resolution, an apology, and the reassurance that the problem will not
happen again to them or to others.
The more the organization depends on repeat business and recommendations
from past patients through word-of-mouth reputation, the more critical it is that
the complaints of its customers are acknowledged and acted on. Some health-
care organizations report their complaint investigations back to those patients who
made the complaint in detail, including information on what people were affected
and what systems were changed. In that way, the organization shows it is respon-
sive to the patients complaint and gives the complainant a sense of participation in
the organization, which may positively enhance loyalty and increase repeat visits.
If the complaint identies a aw the organization can correct, and if knowledge
of the correction provides the patient with a sense of satisfaction for reporting a
complaint that was important and acted on, a true winwin situation results.
Some numerical measures that organizations collect as a matter of normal pro-
cedure can point to real and potential service problems. Total stafng or nurse
stafng per patient day is an example. Although it is used primarily to keep track of
costs, stafng varies by department, oor, or shift. If one shift is signicantly below
the norm, this may indicate possible service problems.
Healthcare organizations should also collect meaningful measures of employee
performance as it relates to service recovery. Positive reinforcement and incentives
should be offered for solving problems, but this requires a good system for measur-
ing customer satisfaction. Salary increases and promotions could then be linked to
an employees achievements in these areas. Likewise, there should be disincentives
for poor handling of customer complaints.
Chapter 14: Fixing Healthcare Service Failures 375
On the positive side, organizations should spotlight employee successes in cus-
tomer service using available media such as in-house publications, the intranet, and
bulletin boards. Such success stories may also be shared during customer service
or culture trainings. Rewards and recognition should ow to heroes in service re-
covery, including those who helped to develop systems for handling complaints or
provided extraordinarily helpful treatment after a service failure (Michel, Bowen,
and Johnston 2008).
Consumers in the healthcare industry are reluctant to complain because they
fear they may receive lower service quality if and when the need for future care
arises (Fottler et al. 2006). Fewer than half of the patients who have a negative
experience with a hospital actively try to change the unsatisfactory situation. This
suggests that written complaints only reect a small portion of total complaints
(Berry and Seltman 2008).
Employee-Driven Strategies
Employees, especially direct or frontline providers, should be trained to handle
service failures and to creatively solve problems as they occur. Scenarios, game play-
ing, videotaping, and role playing are good strategies for developing employees
service recovery skills. Just as umpires can be trained to recognize balls and strikes,
healthcare personnel can be trained to recognize and x service errors.
Do Something Quickly
The basic service recovery principle is to do something positive and to do it quickly.
Strive for on-the-spot service recovery. Capturing the many benets of quick recov-
ery is one major reason benchmark service organizations empower their frontline
employees to exercise discretion in correcting errors. Employees of one service or-
ganization carry a card on which the following three principles of service recovery
are written:
1. Any employee who receives a customer complaint owns the complaint.
2. React quickly to correct the problem immediately. Follow up with a telephone
call within 20 minutes to verify that the problem has been resolved to the
customers satisfaction. Do everything you possibly can to never lose a
customer.
3. Every employee is empowered to resolve the problem and to prevent a repeat
occurrence.
376 Achieving Service Excellence
Many times, customers will log complaints with the nearest employee they can
nd, so organizations benet from asking employees to attempt to capture the
complaint as soon as possible. The physician or staff member who initially receives
a complaint should complete a patient complaint form, and staff members who
receive the complaint should immediately refer the patient to management per-
sonnel. Even if a manager is not immediately available, the staff member should
complete the form and begin to take action because complaints must be captured
as soon as possible.
Other suggestions for service recovery include the following (Grugal 2002):
Ask patients the critical question, What can I do to make this right?
Evaluate the complaint to identify signifcant dissatisfers.
Write down the specifcs.
Communicate and interact in a pleasant manner.
Management must empower employees with the necessary authority, responsi-
bility, and incentives to act quickly after a problem occurs. The higher the cost of
the problem to the patient in terms of money, personal reputation, or safety, the
more vital it is for the organization to train the healthcare staff to recognize and
deal with the service problem promptly, sympathetically, and effectively. Of course,
empowering staff to resolve problems will not be sufcient if recovery mechanisms
are not in place. If the rest of the system is in chaos, empowering the front line will
not do much good.
A quick reaction to service problems has numerous benets:
1. It reduces the overall expense of correcting a wrong.
2. It keeps and creates goodwill between the organization and patients and
their family.
3. It generates positive word of mouth that could lead to repeat business or
referral and recommendation.
4. It strengthens the message that customers are valued.
5. It encourages employees to commit to providing high-quality service
consistently.
Address Root Problems
A necessary further step in any service recovery strategy is that employees should
inform their managers about any system failures they encounter, even if they have
already initiated successful recovery procedures. If they do not report the failure,
the problem may recur elsewhere in the organization.
Chapter 14: Fixing Healthcare Service Failures 377
Collecting these data enables management to move beyond reacting to com-
plaints and on to determining the root causes and preventing them from happen-
ing. Cause-and-effect diagrams might focus staff s attention on those areas that
need the greatest improvements.
The reactions of frontline workers to service failures caused by the system have
signicant implications for customer satisfaction. The common reaction is simply
to remove the obstacle or solve the problem and to continue patient care. But an
empowered staff should also be offered incentives for removing the root cause of
the problem to prevent future recurrences.
For example, a nurse may nd that her newest patient was not served lunch.
Assuming that it was an oversight, she might call food service and order the lunch
for the patient. This might solve the immediate problem, but if the underlying
cause was that admissions failed to advise food service of the new patients ar-
rival, the same problem will occur in the future because the root cause was not
addressed.
The best service organizations encourage staff members to address both the
immediate service failure (the symptom) and the root cause. This is facilitated by
including problem resolution as an explicit part of the staff s jobs, allowing enough
time to address the problem, encouraging communication between staff, dedicat-
ing proper attention to problems, and giving incentives/rewards to those who en-
gage in this type of extra work.
Apologize and Let the Customer Vent
All healthcare personnel should be trained to apologize, ask the patients about the
problem, and listen in a way that gives patients the opportunity to blow off steam.
Considerable research indicates that allowing customers the opportunity to vent to
someone with authority (e.g., manager, supervisor, vice president) is an important
step in retaining their patronage (Heskett, Sasser, and Hart 1990).
This strategy is more effective when it is followed up with an acknowledgment,
a thank you, and a tangible reward, even if it is small (Berry 2009). The tangible
reward could take the form of a meal voucher at the hospital cafeteria, and the
acknowledgment could take the form of an apology and thank you letter from the
CEO.
Patients Evaluation of the Recovery Efforts
Patients who have suffered a service failure and lodged a complaint want action.
Procedural fairness refers to whether or not the patient believes organizational
378 Achieving Service Excellence
procedures for listening to the patients side and handling service problems
are fair or merely a procedural hassle full of red tape. Customers also want an
easy process for correcting problems. They think that if the organization failed
them, it is only fair that the organization makes it easy for them to receive a
just settlement.
Interactive fairness refers to the customers feeling of being treated with re-
spect and courtesy and being given the opportunity to express the complaint
fully. If she has a complaint that the service provider is rude, indifferent, or
uncaring, and the manager cannot be found, the customer will feel unfairly
treated. Common sense suggests that a customer who is encouraged to com-
plain, treated with respect and courtesy, and given a fair settlement is more
likely to return than a customer who is given a fair settlement that is offered
with reluctance and discourtesy.
Distributive fairness, or outcome fairness, is the third test patients apply to an
organizations attempts to recover from problems. What did the organization actu-
ally give to the unhappy patient as compensation for the problem? If the patient
complains about a rude housekeeper and gets only a sincere apology because that
is all hospital policy calls for, the patient will feel unfairly treated; somehow were
sorry may not be enough in the patients judgment to compensate for the rude
treatment.
Once again, it all comes down to meeting the patients expectations. The
issue is difcult because each patient is different. Finding the satisfactory com-
pensation may involve methodical trial and error on the organizations part.
Some research indicates that customers feel more fairly treated when organiza-
tions offer a variety of options as compensation for service problems (Berry
2009; Tax and Brown 1998). For example, a physician can offer a patient the
choice of an immediate appointment (if desired) or can offer to ll the patients
prescription for free.
In sum, investing time, money, staff, and effort into service recovery is just plain
good business.
CHARACTERI STI CS OF A GOOD
RECOVERY STRATEGY
In their classic study, Hart, Heskett, and Sasser (1990) believe service recovery
strategies should satisfy several criteria. More specically, service recovery strategies
should be as follows:
Chapter 14: Fixing Healthcare Service Failures 379
Ensure that the problem is addressed in some positive way. Even if the
situation is a total disaster, the recovery strategy should ensure that the
patients problem is addressed and, to the extent possible, xed.
Be communicated clearly to the employees charged with responding to
patient dissatisfaction. Employees must know that the organization expects
them to nd and resolve patient problems as part of their jobs.
Be easy for the patient to fnd and use. They should be fexible enough to
accommodate the different types of problems and the different expectations
that patients have.
Always recognize that because the patient defnes the quality of the service
experience, the patient also denes its problems and the adequacy of the
recovery strategies.
A strategy that does not make some improvement in the situation for the com-
plaining patient is worse than useless because the organization makes it plain that
it cannot or will not recover from a problem even when informed of it. The work
of Hart, Heskett, and Sasser (1990) suggests that most recovery strategies are in
serious need of improvement. More than half of organizational efforts they identi-
ed that respond to consumer complaints actually reinforce negative reactions to
the service. In trying to make things better, organizations too often make them
worse.
One reason that patients view many recovery strategies as inadequate is that the
strategies do not really take into account all of the costs to the patient. Did the doc-
tor miss an appointment? Schedule another one. Is there a busy signal on the tele-
phone line for hospital information? Interject a recorded apology. The organization
may think the relationship is back where it started, but for the patient many costs
are associated with service problems, and effective organizations will try to identify
them and include some recognition of them in selecting the appropriate service
recovery. After all, the fact that the test results were not delivered by the promised
date is not the patients fault, so why should the patient have to suffer additional
mental stress waiting for results? Why should the patient lose more work time as a
result of a provider-cancelled appointment?
Patients clearly think that when a healthcare problem occurs, organizations
need to do more than simply make it right by replacing it or doing it over again.
The high numbers of malpractice suits substantiate that point. For example, if the
excessively long wait beyond the appointed time causes the patient to miss half a
days salary, then the recovery strategy should include not only an apology but also
some compensation for the patients loss of income as well. Outstanding healthcare
380 Achieving Service Excellence
organizations systematically consider how to compensate patients for economic
and noneconomic losses and take extra effort to ensure that dissatised patients
have not only their time and nancial losses addressed in a recovery effort but also
their ego and esteem needs.
Even when the patients themselves make mistakes, good healthcare organiza-
tions help to correct them with sensitivity. They make sure patients leave feeling
good about their overall experience and appreciating how the organizations staff
helped them redeem themselves. Imagine how depressed you would feel if you
came back to the hospital parking lot after a long day of visiting a terminally ill
family member only to nd that you have lost your car keys and are locked out of
your car. You tell the parking attendant, and half an hour later a locksmith hands
you a new set of keys, no charge!
Even though car key problems are not its fault, a customer-oriented organiza-
tion believes the customer needs to be wrong with dignity. It knows that customers
who are angry at themselves may transfer some of that anger to the organization.
To overcome this very human tendency, customer-focused organizations nd ways
to x problems so that angry, frustrated people leave feeling good because a bad
experience has not been allowed to overshadow or cancel out all the good. By
providing this high level of customer service, the healthcare organization earns the
gratitude and future patronage of patients and enhances its reputation when pa-
tients and their families tell external and internal customers stories of these service
successes.
Matching the Recovery Strategy to the Problem
The best recovery efforts are those that address the customers problem. For ex-
ample, suppose a patient tried to contact her physician by phone (as instructed) on
a certain day and time, was put on hold, and ended up leaving a message asking the
physician to return her call. If the return call was never made, a communications
problem undoubtedly occurred, but the result for the patient is that the physician
appears to be uncaring. An appropriate recovery effort might be to provide the
patient with the physicians personal cell phone number.
Categorizing the severity and causes of service problems might be a useful way
to show the type of recovery strategy a healthcare organization should select. In
Exhibit 14.1, the vertical axis represents the severity of the problem, ranging from
low to high, and the horizontal axis divides service problems into those caused by
the organization and those caused by the patient. When severity is high and it is
Chapter 14: Fixing Healthcare Service Failures 381
Exhibit 14.1 Matching the Recovery Strategy to the Failure
the organizations fault (e.g., when a service failure occurs that totally alienates the
patient), the proper response is the red-carpet treatment. The organization needs
to bend over backward to apologize, communicate empathy and caring, and ad-
dress the patients problem, because it will take an outstanding recovery effort to
overcome the patients negative feeling.
The two types of situations in Exhibit 14.1 where the patient caused the
problem provide terric opportunities for the organization to make patients feel
positive about the experience, even though the patients caused the problem. In
a low-severity situation, a sincere apology is sufcient and will make the patient
think the organization is taking some of the responsibility for a situation that was
clearly not its fault. Indeed, some organizations will do even more, if the cost to
make a patient feel better is not substantial. Hospitals will often change meals if
patients say they do not want them, even when the records show the meals were
just what the patients ordered. The wrong meal may not be the hospitals fault,
but the patient feels good that the organization will not make patients pay for
their own mistakes.
The upper-right box represents situations where the problem is relatively severe
and the patient or some external force created the problem. These are opportuni-
ties for the organization to be a hero and provide an unforgettable experience for
the patient. For example, if the patient is late for an appointment because she got
delayed in trafc and arrived when the physician is busy with the next patient,
the receiving nurse can come out and promise that the physician will see the late
patient next.
a patient feel better is not substantial. Hospitals will often change meals
if patients say they do not want them, even when the records show that
the meals were just what the patients ordered. The wrong meal may
not be the hospital's fault, but the patient feels good that the organi-
zation will not make patients pay for their own mistakes.
The upper-right box represents situations where the problem is rel-
atively severe and the patient or some external force created the prob-
lem. These are opportunities for the organization to be a hero and provide
an unforgettable experience for the patient. For example, if the patient
is late for an appointment because she got delayed in traffic and arrived
when the physician is busy with the next patient, the receiving nurse can
come out and promise that the physician will see the late patient next.
CONCLUSION
According to the t arp study, companies that invested in the forma-
tion and operation of units designed to handle complaints realized
returns on the investment of anywhere from ,c percent to i,c per-
cent.
c
These results, and the other research reported in this chapter,
suggest strongly that putting money and effort into service recovery is
good business.
Service recovery rules can and should be developed for staff. For
example, if a customer is unhappy because of an unmet need and the
staff member can meet that need for less than, say, sicc, then the staff
f i xi ng heal t hcar e s ervi ce pr obl ems ,oi
Figure 13.1 Matching the Recovery Strategy to the Failure
Severity of
Failure
Relatively
Severe
Red-carpet
treatment
and apology
Apologize and
fix/replace/
repeat
Provide help
to the extent
possible and
apologize
Relatively
Mild
Apologize
and extend
sympathy
Organization Patient
Cause of Failure
Fotter/book 8/12/02 3:47 PM Page 361
382 Achieving Service Excellence
CONCLUSI ON
Service recovery rules can and should be developed for staff. For example, an
employee should be given permission to spend a specic sum to correct a ser-
vice problem. If the cost is beyond the limit an employee is allowed to spend,
the staff member should contact her supervisor to discuss other alternatives or
to seek approval for the expense. In this way, staff are empowered to x the
problem on their own without any bureaucratic delay that could cause an un-
happy customer to defect.
In addition, staff should be trained on what to do and say to a patient in the
event of a service failure. Employees must be told that they will not be criticized for
overserving customers, that risk taking and innovative approaches to please cus-
tomers are encouraged, and that service failures and recovery are monitored. The
latter requires installing a system for collecting detailed information on customer
dissatisfaction and defection. Gathering such information should involve frontline
staff, as they are intimately familiar with the service problems that take place and
thus can help the organization determine the root causes and prevent them from
happening.
Learning from failures is more important than xing problems. It is crucial to
address the system and process problems that cause the failure in the rst place.
Service Strategies
1. Realize that service-failure prevention is superior to and less costly than
service-failure recovery.
2. Encourage patients to complain; a complaint is a gift.
3. Train and empower your staff to nd and x problems.
4. Train your staff to listen to dissatised customers with empathy, and then
record the service problem and its resolution.
5. Find a solution the customer believes to be fair, and help patients x service
failures they caused.
6. Remember that unhappy patients tell twice as many people about their
dissatisfaction than happy patients tell others about their excellent
experience.
7. Find out and share with employees how much a dissatised patient costs
the organization to illustrate the importance of service recovery.
8. Address the root causes of service failure.
383
A good leader is best when the people barely know he leads. A good leader
talks little but when the work is done, the aim is fullled,
all others will say, We did this ourselves.
Lao-tzu, Chinese philosopher
C H A P T E R 1 5
Leading the Way to Healthcare
Service Excellence
Service Principle:
Lead others to provide a superb healthcare experience
Providing an excellent healthcare experience is simple. Study your patients
and other customers to nd out what they really need, want, and expect, and then
provide those and maybe even a little bit more. Healthcare managers committed to
providing a superb total healthcare experience do not stop studying their custom-
ers, using all available scientic tools.
Because no two customers are alike and their personal preferences and condi-
tions change, this process of discovery is never complete.
The service product, the service environment, and the service delivery system
must change or evolve along with and to complement the customers. The informa-
tion from this continuous study is used to shape the decisions on strategy, stafng,
and systems.
This chapter brings together the books important concepts to help the health-
care manager achieve service excellence. In this chapter, we address the following:
A model of service excellence in healthcare
Our view of healthcare in the future and the leaders role
Again, we emphasize that service excellence is insufcient by itself in meeting
patient needs, wants, and expectations. Excellent clinical service that successfully
addresses the patients health concerns is the prerequisite to service excellence.
384 Achieving Service Excellence
A SERVI CE EXCELLENCE MODEL
Exhibit 15.1 presents a conceptual framework for achieving service excellence that
shows the impact of service excellence on a healthcare organization. The box on
the left outlines some of the major environmental trends currently affecting or
expected to affect organizations. Some of these may impede and others may po-
tentially help the efforts of organizations to enhance customer service. Among the
most signicant of these environmental trends are consumer-driven healthcare, a
shortage of primary care providers, and potential health insurance reform.
The external environmental and other factors noted in Exhibit 15.1 affect the
structures, processes, and outcomes of healthcare organizations. Among these ef-
fects are increased incentives for organizations to develop more customer-focused
strategies, stafng, and systems. If successful, such strategies, stafng, and systems
should enhance patient satisfaction in the short run (Platonova, Kennedy, and
Shewchuk 2008). If sustained over the long run, this customer-focused approach
will improve customer loyalty to the organization (Garman, Garcia, and Harg-
reaves 2004; Platonova, Kennedy, and Shewchuk 2008). Similarly, it will increase
the probability that the patient will return for service and recommend the organi-
zation to others (Platonova, Kennedy, and Shewchuk 2008).
More organizations are realizing that patient loyalty and retention are para-
mount issues (Bendapudi et al. 2006). The feedback loop (as shown in Exhibit
15.1) indicates that a customers intention to return to and recommend an organi-
zation are associated with increased revenue and reduced resource demands, which
positively affect the organizations structure, process, and outcomes (Evanschitzky
and Wunderlich 2006; Platonova, Kennedy, and Shewchuk 2008). The process is
continuous because more resources enable the organization to enhance its service
product, environment, and delivery system.
External Environmental Changes
Healthcare Reform and Consumer-Driven Healthcare
The Obama administration puts a high priority on health insurance reform, high-
lighting that an estimated 45 million Americans are uninsured. Hospitals, insur-
ers, government ofcials, managed care providers, corporations, and academicians
have also proposed a wide variety of reforms, most of which do not give a high
priority to consumer choice.
One exception is Regina Herzlinger (2007b), who advocates for a consumer-
driven healthcare system in her book Who Killed Healthcare? Herzlinger proposes
the following:
C
h
a
p
t
e
r
1
5
:
L
e
a
d
i
n
g
t
h
e
W
a
y
t
o
H
e
a
l
t
h
c
a
r
e
S
e
r
v
i
c
e
E
x
c
e
l
l
e
n
c
e
3
8
5
Exhibit 15.1 Service Excellence Process and Associated Outcomes
Changing Environment
Healthcare reform
and consumer-driven
healthcare
Increasing
documentation of
clinical and service
outcome
Shortage of primary
care providers
Potential
reimbursement
reform
Healthcare Organizations
Structure, Processes, and
Outcomes
Clinical outcomes
Service outcomes
Customer Service Stafng
Enhanced
recruitment and
retention
Enhanced training
for customer service
Enhanced employee
rewards and
recognition
Discretionary
coproduction
Customer Service Systems
Enhanced
communication and
information
Redesigned service
delivery system
Reduced waiting
Enhanced service
recovery
Customer Service Strategies
Enhanced planning
Upgraded
environment
Enhanced service
culture
Patient Decisions
and Organizational
Outcomes
Patient decision to
return
Patient decision
to recommend to
others
Enhanced fnancial
returns
Patient
satisfaction
Patient
loyalty
386 Achieving Service Excellence
Consumers tailor their own healthcare coverage in a national insurance
market.
Everyone must buy insurance, and the federal government maintains strict
oversight to ensure price and coverage fairness.
Small, disease-specifc hospitals care for patients who do not need all the
services offered by medical centers.
A national database contains the prices and outcomes for procedures at every
hospital and clinic so that consumers can make informed choices.
Individuals get generous tax breaks to buy their own insurance, and subsidies
are provided for those with low incomes.
In other words, Herzlinger asks, Why cant healthcare be run like the retail sec-
tor? (Arnst 2008). If hospitals, insurers, and doctors all had to compete in the
open market for patient customers, she believes innovation would ourish, prices
would drop, and quality would improve.
Herzlinger does not want anyone but consumers managing health benets.
Given that the average consumer is able to choose between 240 makes and models
of cars, why cant they do the same when it comes to their health? In other words,
regardless of who pays for the health benets, Herzlinger would like consumers to
have a wide range of options regarding the selection of providers. That decision
would be buttressed by widespread information on prices, clinical quality, and
service quality.
For those who believe government agents, employers, and private insurance
companies are best suited to make healthcare decisions, consumer-driven health-
care is anathema. They are united by two common beliefs (Kapp 2007):
1. Patients are not able to act as intelligent consumers when it comes to
healthcare.
2. Consumer-driven healthcare will result in loss of their money, power, or
control.
These people prefer a top-down command-and-control approach to healthcare
reform that will not emphasize customer choice and service as primary goals. They
would limit consumer choices to the best options as dened by experts in the
eld. Such a limitation will likely reduce consumers perception of the overall qual-
ity of the services received.
For those who respect consumers ability to make choices, however, healthcare
reform represents a tremendous opportunity; that is, if the reform that passes ends
Chapter 15: Leading the Way to Healthcare Service Excellence 387
up to be centered on choice and service excellence. In addition, it should reward
providers who achieve excellent clinical and customer service outcomes. However,
if the special interests in the healthcare industry (e.g., insurers, pharmaceutical
companies) sabotage a consumer-oriented reform and enhance the command-and-
control approach, the average American may experience a less responsive and more
bureaucratic healthcare system in the future (Kapp 2007).
In 2007, the federal government began posting patient satisfaction scores for
hospitals (see HCAHPS [Hospital Consumer Assessment of Healthcare Providers
and Systems] on www.hcahpsonline.org). The HCAHPS and state governments
posting of hospital prices and quality measures (including patient satisfaction) give
consumers greater transparency in healthcare practices and outcomes, regardless of
the outcome of the proposed healthcare reform. Consumers have been increasingly
considering customer service, price, ease of access, clinical quality, and ethics of the
provider in assessing their healthcare options, regardless of whether or not health-
care reform is characterized as consumer driven (Bodnar 2007).
In other words, clearly, the healthcare reform debate has touched on many is-
sues paramount to consumers, including who will pay for services, how providers
and insurers will be held accountable, and how quality and choices will be man-
aged. Final answers to these questions have not yet been determined; however, the
2009 reform will have a major impact on the quality of customer service experi-
enced in the future.
Increased Documentation of Clinical and Service Outcomes
As customer service information becomes readily available to providers, employers,
insurers, and consumers, performance-based reimbursements will likely increase
along with the importance of customer service. In addition, stakeholders will con-
sider ease of access, clinical quality, and effectiveness of treatment in evaluating
the value of a provider. As calls for public accountability and data transparency
intensify, the concepts and principles discussed in this book can help organizations
make adjustments to improve their overall service and quality performance. Ignor-
ing service excellence will be costly to an organizations bottom line.
The retail clinic trend may also enhance the documentation of clinical and ser-
vice outcomes (Fottler and Malvey 2010). Advances in technology will boost the
transparency, low cost, and easy access to services offered by retail clinics, allowing
these clinics to make public the service and clinical outcomes they have achieved.
Eventually, such clinics may begin to offer specialty services as well. Wal-Mart and
other major retailers would not be entering this eld if consumers were satised with
the access, quality, and prices available to them in the current healthcare system.
388 Achieving Service Excellence
Shortage of Primary Care Providers
In 2008, the Physician Foundation commissioned a survey of every primary care
doctor in the United States, and the results suggest that primary care doctors are an
endangered breed (Rubin 2008). More than three of four respondents said they be-
lieved the United States is facing a shortage of primary care physicians. Moreover,
this perception of a shortage could grow more critical, as half of the respondents
said they planned to reduce their patient load or stop practicing within the next
three years. More than half of the respondents said they would not recommend
that young people pursue careers in medicine because of red tape and payment
issues. These results indicate that the healthcare system tends to undervalue what
primary care doctors do.
To keep up with service demands over the next decade, the United States must
add 40,000 physicians to its current pool of practicing providers, or else the coun-
try will face a soaring backlog (Associated Press 2009). The current shortage in all
physician specialties is expected to worsen. A study by the Association of American
Medical Colleges found that the rate of rst-year enrollees in U.S. medical schools
has declined steadily since 1980, and if this pattern continues, the country will
have about 159,000 fewer doctors than it needs by 2025 (Associated Press 2009).
The survey results are relevant to the concept of service excellence in healthcare
because primary care physicians are often the rst provider a patient sees. Research
shows that a sustained relationship with a primary care physician, as well as the
resulting comprehensiveness of care, organizational accessibility, and coordination
of care, is associated with higher levels of patient satisfaction (Donahue, Ashkin,
and Pathman 2005; Saultz and Albedaiwi 2004) and better treatment outcomes
(Parchman and Burge 2004). If primary care physicians are overworked and un-
derstaffed, patients will have long waits for appointments, and time spent with the
physician will be minimal. The shortage of primary care providers is exacerbated
by the fact that a shortage of nurses and allied health professionals, such as physical
therapists, is ongoing.
This shortage of primary care physicians is a problem that must be addressed
because it is difcult to imagine high levels of service excellence without them. Fed-
eral subsidies for the education of primary care physicians as well as other health
professionals appears to be a necessary prerequisite for achieving long-term service
excellence.
Potential Reimbursement Reform
Under the current reimbursement system, physicians are reimbursed for proce-
dures but not for such activities as e-mail and phone communication, listening
to patients, coordinating care for patients, and so on (Szabo 2007). All of these
Chapter 15: Leading the Way to Healthcare Service Excellence 389
activities are related to customer satisfaction, so changes in reimbursement that
recognize the importance of these activities for enhancing the healthcare experi-
ence of patients is overdue. Whether it will occur under a command-and-control
healthcare reform or a consumer-driven reform remains to be seen.
For example, physicians agree that patients with chronic conditions, such as
cancer, deserve coordinated care provided by a team of healthcare professionals.
However, most doctors do not have time for group consultations, are not used to
working in teams, and are not reimbursed for many of the services teams provide
(e.g., spiritual counseling, social work) (Szabo 2007). Providing such services re-
duces future costs for the healthcare system, but the physicians themselves receive
no nancial benets because they are not reimbursed for these activities. Providing
coordinated care through a team of healthcare professionals would require chang-
ing the way Medicare, Medicaid, and private third-party insurance pay for care.
Changes in reimbursement to pay for the softer side of healthcare can sig-
nicantly increase customer service, healthcare outcomes, and patient satisfaction.
Whether such changes are incorporated in the nal healthcare reform plan remains
to be seen and may be difcult to implement in light of the current economic
downturn. Thus far, health insurance reform has aimed to cover more people and
to expand reimbursement for current procedures. Discussions about reimbursement
for better communication, better clinical outcomes, and better customer service have
not been as intense.
STRATEGY
Today, an amazing amount of information is available about patients and what the
competition offers in providing services to those patients, and only the organiza-
tions that tap into that information to truly understand what their patients and
other customers want will survive and prosper. They must use this information to
design a corporate strategy, discover which of their competencies customers con-
sider to be core, and then concentrate on making these core competencies better.
For example, they use the customers wants, needs, and expectations to sharpen
their marketing strategies, budgeting decisions, organizational and production sys-
tems design, and human resources management strategy.
Southwest Airlines is an excellent example of a company that has used its un-
derstanding of the customer to discover and then provide what its passengers re-
ally want. Like most organizations, Southwest originally used customer surveys
to ask what customers wanted and found customers wanted everything: cheap
fares, on-time performance, great meals, comfortable seats, free movies, and more.
390 Achieving Service Excellence
Southwest realized it could not give its customers everything, so it did additional
research to dig deeper into customer preferences and learned that its customers
really wanted low fares, reliable schedules, and friendly service. The Southwest
product is now exactly what its target market wants and, more importantly, wants
enough to pay for and return to again and again.
The point of this example for healthcare managers is that they must dig deeper
than the simple market survey of patient preferences to understand what prefer-
ences actually drive patient behavior. The organization can use the results from
deeper probing to match the organizations core competencies and mission with
what the customers want.
Key Drivers
Outstanding organizations study their patients extensively to discover the key driv-
ers of their healthcare experience. Some drivers are highly inuential, and some
seem relatively unimportant. Nonetheless, they all contribute to the impression
the patient takes away from the healthcare experience and help determine whether
or not that patient will be satised. A trip to a hospital, or a visit to a physicians
ofce or clinic, is a holistic experience to most people; excellent customer service
organizations do the research necessary to identify all the separate components of
this whole experience. Then they carefully manage them all.
In a sense, key drivers can be divided into two categories. The rst category
consists of basic things patients expect the organization to offer its patients to oper-
ate in the particular market segment. For example, customers expect the following
basics from a hospital: nice, clean rooms; acceptable food; appropriately trained
and skilled medical and professional staff with a decent bedside manner; a caring
attitude; efcient work systems; a clinical product of high quality; and no irrita-
tions in the environment.
The organization must meet these basic expectations, or customers will be dis-
satised. If the organization habitually fails to meet these basic expectations, it
will fail altogether. Organizations must offer the basic characteristics if they seek
to maintain a reputation and attract the repeat business that leads to long-term
success.
The second category of key drivers encompasses the characteristics and qualities
that make the experience memorable. These are the features that differentiate the
experiences at an excellent organization. Benchmark organizations nd a way to go
beyond meeting the basic expectations with which patients arrive when they come
in the door to have a medical need addressed. Outstanding organizations provide
Chapter 15: Leading the Way to Healthcare Service Excellence 391
the key factors that make a difference, make the experience memorable, compel pa-
tients to return again and again, and even motivate patients to tell all their friends
about these exceptional organizations.
The following organizations survey customers to determine how well they are
providing the basics that patients need, want, and expect: Holy Cross Hospital
in Chicago; Sharp HealthCare in San Diego, California; SSM Health Care in St.
Louis, Missouri; Baptist Health Care in Pensacola, Florida; St. Marys Hospital in
Green Bay, Wisconsin; Parkland Health & Hospital System in Dallas, Texas; and
Albert Einstein Healthcare Network in New York. These organizations also use a
variety of techniques to identify the key drivers that determine how customers view
the total healthcare experience.
The key drivers of patients and other customers will vary from one facility to
another. For example, a managed care company may nd that its customers want
easy access online, responsive and knowledgeable customer service representatives,
and an unchanging panel of providers. For a primary care physician practice, the
key drivers might be the possibility of quick appointment scheduling, physician
promptness in seeing the patient at the appointed time, and clear communication
from the physician and nurse.
Generally speaking, the key drivers reect expectations related to clinical out-
comes, behaviors (i.e., being treated with respect and dignity), systems and pro-
cesses (i.e., the way patients are scheduled for tests), and the environment (i.e.,
cleanliness and ease of navigation). Each organization needs to identify its custom-
ers key drivers in general and then do the same for customers in each department
and/or service/product line. Customers for certain services or products may have
different expectations from customers for other services or products. An emer-
gency department (ED) patient, for example, has expectations different from those
of a maternity-ward patient.
An organization cannot know what factors in the service product, the environ-
ment, and the delivery system are key to patient satisfaction and intent to return
until it carefully studies all of these drivers. Many times, what management learns
in such studies is a surprise because what management thought were key drivers
may not turn out to be so from the patients point of view. This service gap is
the difference between what the organization delivers and what the patient needs,
wants, and expects. No matter how much patient data it collects and analyzes, the
organization may still be surprised occasionally by what patients say are important
to them.
Excellent organizations not only study their patients extensively but also accu-
mulate the information they have learned about patients, individually and collec-
tively. Computerized databases and sophisticated techniques of database analysis
392 Achieving Service Excellence
allow an organization to know a great deal about its patientsas a demographic,
as a psychographic group, or as individuals. The best organizations mine these da-
tabases to dig up as much information as they can about what is important to their
patients so they can ensure that they provide what is expected.
Extras
Outstanding organizations that attract repeat patients accumulate patient informa-
tion that may be used to customize the service experience. In other words, these or-
ganizations know that the best get even better by wisely using customer databases
to personalize each patients healthcare experience according to her unique needs,
wants, and expectations.
Some hospitals have developed systems for making each patient feel special by
letting each manager view the service experience for a particular diagnosis from the
patients perspective. For example, a manager might follow a patient undergoing an
MRI (magnetic resonance imaging) procedure so that he too can experience every
step of the process. Within 24 hours, the manager calls staff to a debrieng session,
during which participants discuss the experience and any problems encountered
and then brainstorm solutions. Later, the manager documents the experience and
the items discussed at the session, including key observations, improvement op-
portunities, and recommendations. In this way, not only does the organization get
a chance to improve its service product and strengthen its managers commitment
to customer service, but the patient being observed and monitored also gets to feel
special.
Knowing what makes each patient feel special enables organizations to add the
differentiating factors and extras all excellent organizations want to provide to keep
their patients so satised they will want to return if and when they need treatment
again. The little bit more than the patient expected can make the difference; it can
turn a satisfactory experience into a memorable one and can keep the organization
at the top of the customers mind when thinking about where to go the next time a
particular patient service is desired or when making recommendations to others.
These extras can be built into the service product, the environment, the service
delivery system, or across all parts of the service experience. Based on knowledge
about patient key drivers and likes and dislikes, the designers of the experience can
build in those things that will make a noticeable positive difference in the patients
mind. They should, however, always follow up to develop the metrics that will
allow them to know if they were successful and, if not, they should initiate efforts
to nd out where and why they failed.
Chapter 15: Leading the Way to Healthcare Service Excellence 393
The extras do not have to be expensive, complicated, or elaborate, although
they may be. Bedside manner does not cost anything, for example, but certain en-
vironmental features may be quite expensive. Florida Hospital in Orlando has cre-
ated a staff positionconciergefor its orthopedics unit. This position involves
being a contact person for each patient and making sure that each patient receives
a seamless healthcare experience.
Planning
Providing the patient with both the expected parts of the healthcare experience and
the extra or differentiating factors is the result of extensive planning. And this plan-
ning always starts with the patient. Capacity and location decisions, stafng plans,
the design of personnel policies, and the selection of medical equipment must all
be based on the organizations best information on what kind of experience the
patient wants, needs, and expects from the organization.
If the organizations mission is to build a chain of freestanding doc-in-the-
boxes, then it must identify what stafng, locations, medical equipment, exte-
rior appearances, and clinic sizes it should have. These decisions can be properly
made if they are based on solid and extensive customer research. Organizations
that understand the key drivers of a healthcare experience use the best data they
can gather. Although many organizations still base these decisions on a variety of
factors, benchmark institutions always start with the patient and make sure every
decision is based on a thorough knowledge and understanding of the patient.
Feedback
Benchmark organizations also know that the discovery process is never ending, so
they constantly seek feedback from their customers about what works and what
does not. Patient needs, wants, and expectations change, and the best organizations
change as well in response to evolving patient expectations. Those organizations
that constantly seek to exceed patient expectations build in their own future chal-
lenges. Todays extras are tomorrows standard patient expectations.
Outstanding organizations are constantly trying to outdo their present perfor-
mance, and they survey customers constantly to determine how well they are satis-
fying their key drivers. For example, a medical group practice had a long history of
complaints and frustrations associated with a paper scheduling system for patient
appointments. As a result of survey data from three customer groups (i.e., physicians,
394 Achieving Service Excellence
staff, and patients), a new online appointment system was installed. Success indica-
tors were then developed to evaluate the results of the new system, focusing on key
drivers suggested by each of the three customer groups. Signicant improvement in
satisfaction of all three customer groups resulted from this process.
Culture
Managers of outstanding organizations should remember the importance of the
organizational culture in lling in the gaps between what the organization can
anticipate and train its people to deal with and what actually happens in the daily
encounters with a wide variety of patients. Anticipating the many different things
patients will do, ask for, and expect from the service provider is impossible.
Thus, the power of the culture to guide and direct employees to do the right
thing for the patient becomes vital. Good managers know that the values, beliefs,
and norms of behavior the culture teaches its employees are critical in ensuring that
the patient-care staff do what the organization needs them to do in unplanned and
unanticipated situations, even if the organization has no specic policies relevant
to that situation.
The culture must be planned and carefully thought through to ensure that the
message sent to all employees is the one the organization really wants to send. An
important part of any strategy is to ensure that everything the organization and
its leadership says and does is consistent with the culture it wishes to dene and
support. The more intangible the healthcare product, the stronger the cultural
values, beliefs, and norms must be to ensure that the provider delivers the quality
and value of healthcare experience the patient expects and the organization wants
to deliver.
Service or Price
In the future, healthcare organizations will tend to compete on service or price
even more than they do now. A successful group of organizations in every service
sector will seek to add value to each customer service encounter (like the strategy
of Pearle Vision) or seek to dene value on price alone (like the strategy of discount
opticals). By focusing on a particular niche of the market, advertising to that niche,
and then serving that niche well, these companies (like Southwest Airlines and
retail health clinics) will thrive. However, healthcare organizations typically market
their services based on some combination of clinical effectiveness, service quality,
Chapter 15: Leading the Way to Healthcare Service Excellence 395
and (possibly) price. In other words, they market based on value received rather
than price alone.
Low-cost providers may appeal to price-conscious consumers by using technol-
ogy to become more efcient. High-cost providers can increasingly customize the
product to each patients expectations at the price point plus offer a little bit more
because they can provide their employees with the necessary information to per-
sonalize the service in a prompt, friendly, and efcient way.
The healthcare businesses between these two ends of the spectrum will have the
most difcult challenge. They will be challenged to offer patient services that are
as personalized as those offered by the high-cost organizations, while providing the
low prices that the price-oriented rms offer. This middle group of organizations
may do neither very well. They may nd themselves in the position of overprom-
ising and underdelivering, which is not the way to have satised, loyal, or repeat
patients.
STAFFI NG
Stafng has become an increasingly important factor for all healthcare organiza-
tions as they realize that the most effective way to differentiate themselves from their
competitors is through the quality of the service encounters the patient-contact
staff provide. Competitors can readily imitate the service product, the physical
elements of the environment, and the technical aspects of the delivery system,
but not the people. For example, each hospital or clinic may have nearly the same
physical equipment as every other hospital/clinic. It will not take long for one hos-
pital or clinic to duplicate the factor that makes its competitor successful. Any new
machine or system is an innovation only for as long as it takes the competition to
replicate it.
Employee Engagement
People, not MRI technology, make the difference. If one clinic has friendly em-
ployees and another clinic does not, customers will go to the friendly one, unless
their HMO requires the second. When all other factors are equal, or nearly so, the
healthcare staff make the difference. The challenge for healthcare managers is to
empower the service provider to engage each patient on a personal, individual basis
while still maintaining production efciency and consistent quality in the service
delivery process.
396 Achieving Service Excellence
For example, a pharmacist is responsible for lling prescriptions exactly as pre-
scribed in an efcient fashion that respects a patients time constraints. He can han-
dle the transaction in an impersonal manner (barely speaking to the patient). Al-
ternatively, the patient can be engaged in a conversation about other prescriptions,
any allergic reactions to drugs, the weather, or inquiries about family members (if
known to the pharmacist). If the pharmacist just processes people, he may become
bored. If he engages them, the job becomes more interesting. The latter approach
is much more likely to enhance the patients relationship with the provider and to
make way for a healthcare experience that exceeds expectations.
The division will widen between organizations that can engage all the capa-
bilities of its employees and those who use employees only from the neck down.
Value added to the healthcare experience through the skills of employees engaging
in service encounters will become a more important differentiating strategy as the
decreasing costs and increasingly available technology make the healthcare product
and service delivery system components (except for people) increasingly easy to
duplicate and emulate by all competitors. If all eye exams are essentially alike, the
feel-good part of the eye exam becomes an increasingly important part of the total
experience.
Advertising alone cannot provide this difference and, in fact, may be counter-
productive if patients do not encounter what the glowing ads lead them to expect.
Staff members can make the difference that patients remember. If your patients
continue to think and speak well of you, you must be doing something right. If
they do not speak well of you and do not hold your organization in high regard,
then implementing the principles outlined in this book will move you toward
healthcare excellence. If their continued high regard is vital to your organizations
survival, you better nd a way to keep it.
Selection and Training
Some employees gure it out, engage their customers, and actually do have fun.
They are usually the ones who were selected properly in the rst place. Finding the
right people for patient-service jobs is an important responsibility of the selection
process. Putting the right people in these jobs eliminates many of the problems in
delivering high-quality healthcare experiences. Some people are just plain good
at quickly establishing personal contact with patients, and they can be identied
through effective selection techniques. Finding these people and training them in
both the cultural values and the basic engagement skills necessary for effective ser-
vice delivery are key responsibilities for healthcare human resources managers.
Chapter 15: Leading the Way to Healthcare Service Excellence 397
Recall that patient-contact employees have three responsibilities in the service
encounter: They deliver the service (or in some cases create it on the spot), they
manage the quality of the encounters or interactions between the patient and the
organization, and they identify and x the inevitable problems. Too many orga-
nizations train only for the rst responsibility and neglect the other two. In many
instances, receiving the service product is just one element in the patients determi-
nation of the quality and value of the experience. Employees must also be trained
to deal effectively with the variety of personalities and concerns that different pa-
tients will bring to the healthcare experience.
Selecting the right person for the job starts by clearly dening what the job
requires. If you want a person to be a receptionist, who serves as a pleasant, rea-
sonably informed rst point of contact for new patients, then hire someone with
a certain bundle of skills. If you want a person to be a triage decision maker, who
not only serves as the rst point of contact but also decides who needs immediate
treatment and who does not, then hire someone with skills different from those
of a good receptionist. Leaders should also allow peers to participate in selection
interviews as these are the people who will be working with the new employee.
Studer (2008) has recommended re-recruiting new employees at 30- and 90-
day intervals. The purpose of these 30- and 90-day interviews is to make sure that
the employee is on board, her expectations are being met, and the goals of both
supervisor and employee are aligned. On-board means the employee has bought
into the goals, requirements, and behavior of staff members necessary to imple-
ment a customer-service culture. A major purpose is also to enhance retention of
new employees, as they often leave within the rst three months.
The second part of the stafng issue is training. Studer (2008) recommends
that leaders be trained rst, because it makes no sense to train employees and align
their behavior with the organizations mission, vision, values, and strategies if the
top management team is not also aligned. The right person in the right job must
be trained to do it the right way. Some jobs in the healthcare industry are repeti-
tive, simple, and boring; others are also repetitive and boring but complex instead
of simple. Both require incredible attention to detail and concentration on task
performance so the employee provides the same healthcare experience in the same
awless way for each patient.
An employee can easily lose focus, daydream, or otherwise lose interest in tak-
ing blood from the 30th person of the day. By that time, his arms are tired, his
attention span is short, and his interest in greeting one more patient with a friendly
smile and positive eye contact is about zero. Part of that employees training should
include how to cope with the emotional labor that is part of these jobs (Larson and
Yao 2005).
398 Achieving Service Excellence
When the encounters are shortas in a visit to the lab or the billing ofcethe
training challenge is particularly difcult because the staff member must know
how to build a connection to the patient quickly. The use of scripts or scripted
behaviors is one way organizations help employees respond appropriately to the
different expectations of different patients, even when the employee may be bored,
tired, or stressed out.
Rewards and Recognition
Service excellence requires that rewards and recognition be provided for lead-
ers and staff who demonstrate high levels of service excellence. Studer (2008)
recommends identifying low performers, middle performers, and high perform-
ers. For high performers, he suggests more training and development as well as
more recognition and rewards. For low performers, he suggests conversations
that identify deciencies and possible ways the employee must enhance her per-
formance. However, in some cases the person may have to be dismissed from the
organization if performance does not improve. For the middle level of perform-
ers, he suggests continuing conversations, measuring performance, and reward-
ing performance as it improves.
The advantage service organizations like healthcare offer to employees over
typical industrial settings is the positive feedback and stimulation that dealing with
patients can bring, especially when employees know that what they do may make
the difference between sickness and health or life and death. Once employees learn,
through experience or training, how to derive some sense of satisfaction out of
doing something that makes a patient happy, they enjoy their jobs and feel a sense
of accomplishment.
In addition to their paid employees, benchmark organizations rely on volunteers
to provide some of the patient contact. Volunteers may be better able to engage
patients and their families because they have more time to do so. The only ques-
tion is whether they are provided with appropriate rewards and recognition that
motivate them to do so. Recent empirical research indicates that volunteers can
and do make signicant, positive contributions to patient satisfaction (Hotchkiss,
Fottler, and Unruh 2009). Many healthcare organizations have discovered that
some of their best volunteers are older, retired people who are often lonely, bored,
and looking for something to do that will allow them to have positive contact with
other people. Some organizations that originally recruited older people because of
labor shortages have found to their pleasant surprise that many older people bring
an enthusiasm for service that makes them great employees.
Chapter 15: Leading the Way to Healthcare Service Excellence 399
Obviously, all staff members are volunteers in the sense that they can choose to do
more than the minimum required by their job description or not. They work under a
wide variety of nancial or nonnancial rewards, including personal recognition. If or-
ganizations are able to identify and respond to these needs by providing valued rewards
and recognition, they are more likely to achieve higher levels of customer satisfaction.
More and more healthcare employees are looking for job challenges and in-
creased opportunities to be responsible for the patient encounter. The need to trust
the employees and allow them to take on this responsibility will intensify as the
competition for talented employees becomes greater. Good people want to take the
responsibility, and successful organizations are those that nd ways to preserve the
quality and value of the healthcare experience while empowering their employees
to be responsible for patient satisfaction.
Allowing playfulness is an important approach to reward and recognition that
enables staff to release tension in stress-lled settings. Furthermore, most people
like to celebrate, and employees are no different. Celebrations of success can take
the form of parties, balloons, banners, pictures of the honored managers and staff,
and recognition dinners. No success should be allowed to pass unnoticed.
Finally, a customer-focused reward and recognition system requires an excel-
lent performance appraisal system. Because what is measured and rewarded is
managed, leaders should be continually checking on the performance of their
subordinates based on objective measures of the individuals customer service
and other key performance attributes. In addition, the performance evaluation
system needs to be tied to compensation and other rewards valued by the subor-
dinates. Finally, the organization needs to continually monitor employee satis-
faction and take steps to remedy any deciencies to enhance employee retention
and respond to employee concerns.
Standards of Behavior and Performance
One way to ensure understanding of and agreement with the organizations com-
mitment to a customer service mission is to require that before being hired, all job
applicants read and sign a performance standards agreement that species, among
other things, the customer service standards expected by the organization. This
performance standards agreement should be based on input from all employees,
align individual behavior with strategic goals and mission, use specic language,
hold people accountable, and be updated periodically.
A large part of a managers job is to dene employees job responsibilities, goals,
standards of performance, and managements expectations of what behaviors match
400 Achieving Service Excellence
the organizations culture. These must be clearly spelled out, dened with specic
metrics, and reinforced and rewarded by managers every day.
Once a manager lets an employee provide service of less than outstanding quality or
overlooks poor employee performance, the message goes out to everyone that managers
do not always really mean what they say about providing high-quality customer service.
Just as a patient has many moments of truth during the course of a single healthcare
experience, employees have many moments of truth with every manager every day.
What happens during these moments of truth tells the employees a great deal about
what management really believes in. This is where the organizational mission statement,
corporate culture, and corporate policies about customer focus become real.
Just as one employee at one moment of truth can destroy the patients perception
of the entire organization and what it stands for, so too can one supervisor overlook-
ing one violation of patient-care quality standards or job performance change the way
an employee looks at an organization. Although most organizations do a good job of
developing selection techniques and providing the necessary job training, many fall
short in the reinforcement area. When they let things slide, they miss the chance to
reinforce the positive and coach away the negative aspects of employee performance.
Many outstanding organizations require their managers to be in their job areas
walking the walk and talking the talk; it is a vital part of how the message is sent
to employees that everyone is responsible for customer service, including the man-
agers. This policy also builds a sense of community among the employees in that
everyone is there to serve the customer.
Patient and Family
Just as organizations can benet from thinking of their employees as customers,
they can also benet from thinking of their customers as employees. It gives the
organization a different way of looking at and thinking about their customers if
they dene them as quasi-employees.
Customer-employees can serve several important functions. They can be knowl-
edgeable unpaid consultants, as they give helpful feedback to the organization re-
garding their level of satisfaction with the healthcare experience. They can help
create the service experience for other patients, as they are typically part of the ser-
vice environment. If being surrounded by other patients is a necessary part of each
patients experience, then how these customer-employees are used to help create
each others experience becomes an important part of the management process.
Most important, with encouragement and training from the organization, cus-
tomers can become coproducers of their own service experience. Coproduction
Chapter 15: Leading the Way to Healthcare Service Excellence 401
benets both the patient and the organization. It reduces the labor costs for the
organization, and knowledgeable patients (perhaps with the help of their family
and friends) are likely to receive a better healthcare experience because they helped
produce it. In addition, patients do not have to wait for some services that they can
do on their own.
SYSTEMS
The best, most thoroughly trained people in the world cannot satisfy a patient if
they deliver the wrong medicine, operate on the wrong body part, or provide the
wrong therapy perfectly. A huge, complex system (like a university teaching hospi-
tal) and a simple system (like a dental clinic) both have to be carefully managed so
the right product is delivered to patients when they expect it to be.
Patients do not care that the room is not ready yet because the laundry broke
down, or that the organization misplaced a medical shipment so they cannot get
the drugs they need, or that the staff specialists are unavailable because someone
forgot to schedule them. The patient just wants a clean room, the right medicine,
and the right specialist, and the patient wants those now. If these things do not
happen, then the production system, the support system, the information system,
or the organizational system has failed, and someone needs to x itfast.
Models
The most highly developed applications related to providing an excellent healthcare
experience can be found in the clinical systems area. Models of patient behavior in
many situations can be built and used to understand and predict ways in which the
organization can best treat the patients medical condition. Such clinical models
can be extended into modeling all aspects of the healthcare experience. Simulations
are an important technique for doing this, and with the decreasing costs of com-
puters and increasingly user-friendly software packages, simulations will become
more available and relevant to all types of healthcare organizations.
Once the planning process has gotten the design right and the measurement
systems are in place to get patient feedback, the stage is set to use simulations of the
entire healthcare experience to see if it all works as a system. Organizations need to
ensure that the right capacity has been built into their service delivery system. The
design-day selection and the parameters used (such as maximum wait times) drive
the rest of the capacity decisions.
402 Achieving Service Excellence
Because customers are not impressed by excuses such as the computer system
is down today, backup systems need to be in place so that customers are not
inconvenienced. Having managers go through the service delivery process like pa-
tients sensitizes them to potential problems. In many organizations, the most vis-
ible part of the healthcare experience is the wait for care. This wait system, there-
fore, requires extra organizational time and attention to ensure that the inevitable
waits are tolerable and within the limits patients will accept without becoming
dis satised.
Waiting Times
Waiting periods are easily modeled and studied with simulation techniques and
easy-to-use computer software. Everything from the number of beds in a hospi-
tal to the number of physicians on duty in an ED to the number of phone lines
needed at an HMO call center can be simulated based on patient demand data. If
you know how many patients are coming to your place of business and can esti-
mate a predictable distribution to represent their arrival patterns and times for ser-
vice, modeling how the waiting experience can be managed and balanced against
capacity is relatively simple.
Managing the waiting time is important from the capacity standpoint and the
psychological standpoint. Because few can build enough capacity to serve peak de-
mand periods, and few can stockpile their mostly perishable and intangible prod-
uct, managing the patients wait is critical for all organizations. The greater the per-
ceived value of the healthcare experience, the longer the patient will wait. Again,
this area is susceptible to empirical research; how long patients will wait for any-
thing before they give up and leave can be studied, measured, and understood.
Measurement
The excellent organizations of the future will use every tool at their command to
gure out what patients want and then provide it in a way that is consistent with
the patient expectations of value and quality. If they promise a high-quality health-
care experience that includes friendly service, they better provide those features or
patients with other options will not come back. Most organizations depend on the
high regard of their patients, and disappointing them will cost dearly in a competi-
tive marketplace.
Once you tell your customers what you will do for them, you have made a com-
mitment and a promise. If the promise is broken or the commitment unrealized,
Chapter 15: Leading the Way to Healthcare Service Excellence 403
patients will be unhappy and will tell everyone they know how unhappy they are.
Few organizations can afford to break their promises, and the more an organization
depends on a good reputation and positive word of mouth, the less chance it can
take of violating that trust.
Information and opinions about service quality are freely and widely available
now and will become even more so in the future. If a dissatised patient posts a
negative comment on the Web about a service, that comment is readily accessible
to anyone with Internet access. The more the Internet is involved in helping con-
sumers select a healthcare provider, the more critical it becomes to avoid service
failures.
Some major healthcare organizations now have an employee whose only job
is to monitor discussion groups and blogs on the Internet to detect and hopefully
correct patient complaints and false rumors that show up. A job classication that
did not even exist ten years ago is becoming an increasingly important part of the
organizations communication strategy as it seeks to monitor and address the nega-
tive word of mouth or misinformation that now travels instantly across cyberspace
to the entire world.
Measurement is crucially important because what gets measured gets managed
and improved. As noted earlier, feedback given in various forms from both employ-
ees and patients is critical. In this way, the total healthcare experience is transpar-
ent, individual behavior is aligned with strategic goals, people are held accountable
for achieving these goals, and the organization is able to show progress over time.
Consistent Improvement
The future will be information management, people management, an increasing
focus on understanding what each patient really wants (a market niche of one
that allows the organization to build a relationship with each patient), and a focus
on the organizational core competencies that satisfy these patient expectations.
The future will also bring forth more knowledgeable customers with ever-rising
expectations. The more competitors in a marketplace try to outdo each other in
providing superb healthcare experiences, the more familiar these experiences will
become.
Yesterdays exceptional experience becomes todays expected minimum level
of service. Healthcare managers will need to engage the entire organization in
constantly reviewing all aspects of the customer service product, strategy, en-
vironment, and stafng of the service delivery system to innovate new and not
easily duplicated features that make the future patient experience as memorable
as todays.
404 Achieving Service Excellence
The easiest and most fruitful area in which to develop these features is in the
interaction between staff and patients, where healthcare employees can elevate an
expected experience into something that is truly memorable. The challenge here
is to empower them to provide that unique extra touch without jeopardizing the
quality and consistency of the clinical experience. Human error is inevitable, and
the need to blend technology and people to provide a high-tech and high-touch
experience of consistently high quality will be the biggest and most interesting
challenge for the future healthcare manager seeking excellence in the healthcare
experience provided.
Finally, service recovery is crucial. Because no organization is perfect, providing
multiple methods for customers to communicate problems is necessary. The cost
of losing a patient, as well as his family and friends, far exceeds the immediate costs
of making things right.
THE ROLE OF LEADERS
We end this chapter by stressing an idea that has been implied throughout this
book: Managers must lead staff toward excellence. The leader is the symbol and
teacher of what the organization stands for and believes. If the leader does not lead,
all the efforts to discover the key drivers that cause the customer to seek out a par-
ticular healthcare experience; the expense of designing a healthcare environment;
the resources dedicated to building, maintaining, and constantly improving a ser-
vice delivery system; and the effort to recruit and train the best people are wasted.
Every day and in every way, the leaders must set the example and consistently com-
municate to all employees what their value is to the organization and to its mission
of creating the healthcare experience.
Everyone wants to feel that what she does has value and meaning to a purpose
larger than enriching a companys top executives and stakeholders. Leaders not
only inspire their staff to realize their individual worth to the organization but
also help staff see how they contribute to the greater good by doing their jobs with
excellence. Telling people how important it is that they do their jobs well is not
enough; all employees must understand and believe that their contributions make
a difference and that doing well, whatever they do, is vital in making the world a
better place.
Many organizations make efforts in this direction, but only a few succeed.
These benchmark organizations inspire their employees to believe they are respon-
sible for saving lives, relieving human suffering, and healing many who would not
otherwise return to health. These organizations constantly remind all employees
Chapter 15: Leading the Way to Healthcare Service Excellence 405
that what they are doing has a greater purpose than merely giving shots, cleaning
rooms, or emptying bedpans.
Each job has value, and the person doing the job has value because of the contri-
bution to the larger purpose. This is a vital part of inspiring people not only to do a
job but to do it with pride and commitment. Not every employee will be deeply af-
fected, but this idea is planted in so many healthcare employees minds that it creates
the strong cultural reinforcement that focuses everyones attention on producing an
excellent experience for each patient. This is a powerful leadership technique and a
valuable way to ensure that everyone stays focused on the patient.
The commitment and enthusiasm of great organizational leaders is contagious
and leads to involvement and passion among all organizational members. Leaders
nd ways to make employees feel that their jobs are fun, fair, interesting, and im-
portant. Leaders establish a culture of service excellence and reinforce it by word,
deed, and celebration. Leaders give value to employees by showing them they are
appreciated and respected for their contributions to the organization and to the
larger purpose toward which the organization aspires. Leaders have the joy and the
responsibility of making it all happen: happy, motivated staff members; outstand-
ing healthcare experiences; and highly satised patients whose loyalty, goodwill,
and positive word of mouth in the community form the foundation of organiza-
tional service and performance.
Common sense and research suggest that a relationship exists among the be-
havior of organizational leaders, how employees feel about their jobs, and how
that feeling is translated into the level of service they provide. If staff members
feel positive, they provide a high level of service. Creative, high-quality service for
patients links directly to patient opinions, and these opinions are a key part of any
organizations success. This chain reaction all starts with the leaders. In the organi-
zational units where employees rate their leaders as outstanding in such behaviors
as listening, coaching, recognition, and empowerment, the patient satisfaction rat-
ings are invariably the highest.
Finally, the leader blends the strategy, staff, and systems so everyone knows he
is supposed to concentrate on patients and other customers. The strategy, stafng,
and systems must be carefully managed if the combined effort is going to succeed
in providing an outstanding total healthcare experience. If the leader sees that any
element is not contributing to the employees ability to provide outstanding experi-
ences, the leader will x it or have it xed.
Just as the organization wants to x any patient problem that detracts from
the healthcare experience, the outstanding leader wants to x any staff members
problem that detracts from that persons ability to provide the outstanding health-
care experience. Vision, skills, incentives, delivery system, and measurement are
406 Achieving Service Excellence
leadership components that leaders must manage if they are to meet this challenge
effectively. As noted in Exhibit 15.2, all must be present to produce and maintain
highly satised customers. More specically, leaders must do the following:
Defne an organizational vision of what patient segment is to be served and
what service concept will best meet customer expectations (vision).
Establish a customer-focused culture to enhance clinical excellence (vision).
Communicate the organizations mission and vision to all customers on an
ongoing basis through a wide variety of methods (vision).
Select employees with service-oriented attitudes, and train them in the
necessary clinical and customer service skills (skills).
Train staff to exceed customer expectations on an ongoing basis using scripts,
role playing, and other training methods (skills).
Create standards of behavior and performance, and hold staff accountable for
upholding these standards (incentives).
Create and implement the incentives that will motivate empowered employees
to provide unsurpassed customer service (incentives).
Establish a service recovery system that empowers all staff to identify and
rectify all customer service problems (incentives).
Communicate and celebrate all individual and group successes (incentives).
Ensure that employees have the proper resources to provide outstanding
service (resources).
Create a clean and attractive environment for all customers (delivery system).
Design specifc delivery systems that translate plans, employee skills, and
resources into an experience that meets patient expectations and perhaps even
wows the patient (delivery system).
Focus on employee retention and patient retention (measurement).
Provide the measurement tools that allow employees (and coproducing
patients) to see how well they are doing in providing the targeted or desired
healthcare experience (measurement).
Use data generated from the measurement tools to continually identify and
implement improvements in customer service, because success is never nal
(measurement).
Measurement is critical for ensuring that all factors of service are correctly fo-
cused on achieving the best for the patient. Simply, if you do not know how you
are doing, you do not know if you need to do better, and you do not know how to
do better. If you try to improve patient service, you do not know if you have suc-
ceeded unless you implement measurement techniques. Continual improvement is
also necessary given that momentum can easily be lost.
Chapter 15: Leading the Way to Healthcare Service Excellence 407
Exhibit 15.2 shows how the customer and the customers experience can be
negatively affected when leaders fail to manage any one of these important leader-
ship components. However, negative outcomes can be prevented. Just as service
problems happen in the best-managed organizations, so can patient-contact staff
of poorly managed organizations sometimes provide successful healthcare experi-
ences in spite of the organization and its faults. When one or more leadership
components are missing, however, the chances of consistent service success are
reduced. The exact effect on the healthcare experience may not be predictable in
precise terms, but it will not be a happy one.
Exhibit 15.2 also shows how a missing leadership element can affect employees.
Although managers will do as good a job as they can of managing the nonhuman
elements, their ability to change them may be limited. If the clinic is already con-
structed and the laboratory set up, the clinic manager may not be able to manage
the service environment and the mechanical parts of the delivery system much.
In a way this is good news because it enables managers to focus on the people
part of the healthcare experience: the patients as part of the environment for each
Exhibit 15.2 Leadership Components
Finally, the leader blends together the strategy, staff, and systems so
that everyone knows that they are supposed to concentrate on patients
and other customers. The strategy, staffing, and the systems must be
carefully managed if the combined effort is going to succeed in pro-
viding the outstanding healthcare experience that the healthcare organ-
ization was established to provide. If the leader sees that any element
is not contributing to the employees ability to provide outstanding
experiences, the leader will fix it or have it fixed.
Just as the organization wants to fix any patient problem that
detracts from the healthcare experience, the outstanding leader wants
to fix any staff members problem that detracts from that persons
ability to provide the outstanding healthcare experience. Vision,
skills, incentives, delivery system, and measurement are leadership
416 achi evi ng servi ce excellence
Figure 15.1 Leadership Components
Skills + Incentives + Resources + Delivery System + Measurement Vision
= Unfocused Employees = Unfocused Service = Confused Customers
Vision + Incentives + Resources + Delivery System + Measurement Skills
= Untrained Employees = Probable Failed Service = Disappointed
Customers
Vision + Skills + Resources + Delivery System + Measurement Incentives
= Unmotivated Employees = Lackluster Service = Disillusioned
Customers
Vision + Skills + Incentives + Delivery System + Measurement Resources
= Unsupported Employees = Inadequate Service = Complaining
Customers
Vision + Skills + Incentives + Resources + Measurement Delivery System
= Unreliable Employees = Unreliable Service = Unsatisfied Customers
Vision + Skills + Incentives + Resources + Delivery System Measurement
= Uninformed Employees = Inconsistent Service = Unfulfilled
Customers
Vision + Skills + Incentives + Resources + Delivery System + Measurement
= Unsurpassed Employees = Superb Service = Highly Satisfied
Customers
Fotter/book 8/12/02 3:47 PM Page 416
408 Achieving Service Excellence
other, the patients as they participate in creating their own experiences, the clini-
cal and staff as they try to provide outstanding customer experiences, and all other
support staff as they provide the assistance that their internal customers require.
These many and ever-changing elements of the healthcare situation require and
deserve each managers attention.
If the organizations leaders lack an overall vision of the target market and its
expectations, this lack will be communicated from the top throughout the culture
and may lead to unfocused service. Staff members will not be sure exactly what
they are trying to achieve, and patients will receive mixed messages and an incon-
sistent experience. If managers put untrained people in patient-contact positions,
service failures and disappointed patients are the probable result. If incentives are
lacking or inappropriate, unmotivated staff will simply go through the motions of
providing lackluster healthcare experiences.
Failure to provide resource support for all staffclinical and nonclinicalwill
prohibit even a motivated and patient-focused staff from providing adequate ser-
vice. Similarly, aws in the delivery system will keep even the best personnel from
providing reliably satisfactory healthcare experiences, much less superb ones; as the
saying goes, A bad system will defeat a good person every time.
Finally, if levels of service quality and patient satisfaction are not measured,
employees will be frustrated by not knowing whether the healthcare experiences
they are providing are achieving the healthcare mission or not; so in a hit-or-miss
fashion, they will continue to provide inconsistent service.
Only when these components are all in place can the leader be effective in en-
abling and empowering employees. Only then can empowered employees provide
the outstanding healthcare experiences that fulll the organizational vision of pro-
viding remarkable service that exceeds patient expectations. Every manager, from
the chief executive ofcer to the frontline supervisor, must ultimately make sure
that employees feel good about what they are doing, that they convey this feeling
to patients, and that patients leave knowing the experience was worth every penny
paid and maybe a little bit more. Leadership makes the difference between success
and failure in todays healthcare organizations, and it will make the difference in
the future.
CONCLUSI ON
The healthcare experience, despite all its componentsservice product, service
setting, and service delivery systemis not complete without the patient. With-
out the patient, the carefully designed service product; the detailed and inviting
Chapter 15: Leading the Way to Healthcare Service Excellence 409
setting; the highly trained, motivated staff; and the nest facilities and equipment
are just part of an experience waiting to happen. Throughout this book, we have
made the point that everything starts with the patient. We conclude by saying that
everything ends with the patient as well.
Service Strategies
1. Start with the customerboth external patients and internal staff
members.
2. Articulate a vision, transcending any single job, that gives all staff a sense
of value and worth in what they do.
3. Manage all three parts of the organizations service systemstrategy,
stafng, and systemsand focus them on achieving strategic goals related
to customer service.
4. Build a strong customer service culture and sustain it with stories, deeds,
and actions.
5. Organize, staff, train, and reward around the patients needs, wants, and
expectations.
6. Train all staff to think of the people in front of them as their guests.
7. Ensure that jobs are fun, fair, and interesting to help employees provide
superb experiences.
8. Keep in mind the strong relationship between highly satised employees
and highly satised patients.
9. Incorporate customer satisfaction skills into employee training programs.
10. Never stop teaching; inspire everyone to keep learning.
11. Establish a standard of performance, measure it, and then manage it
carefully.
12. Use information to improve strategy, stafng, and service elements
identied by customers as decient.
13. Link customer satisfaction scores to management and employee rewards
and recognition.
14. Prevent every service problem you can, nd every problem you cannot
prevent, and x every problem you nd every time and, if possible, on
the spot.
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411
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431
Index
Access, 78, 9
Accountability, 168
ACSI, 15
Action plans: areas for, 68; performance
criteria, 6869; purpose, 69;
service strategy, 6769
Added value, 10
Administrative skill, 199
Advanced information systems, 25559, 260
Advertising, 241
AI, 25859
Alignment audit: core elements, 7374; cues,
7174; framework, 7374;
organizational factors, 69, 71; questions,
7576; steps, 74; strategic plan, 53
Allied health professional: shortages, 133
Ambient conditions, 9596
American Customer Satisfaction Index. See
ACSI
Anxious waits, 324
Apology, 377
Application form, 149
Appointment: wait time, 303
Arrival pattern, 31314
Arrival rate, 320
Articial intelligence. See AI
Assessment: service excellence model, 4023
Assets, 6162
Attitudinal training, 18182
Avenger, 364
Background checks, 15253
Behavioral change, 174
Beliefs, 1067
Benchmarking, 14546
Benchmark service organizations: lessons
from, 1819
Benet package, 141
Biophilic design, 87
Blueprint: explanation, 27983; playground
injury treatment, 282
Brainstorming, 5758
Branding, 120
CAHPS, 14
Callback, 14344
Capacity day, 31112
Capacity planning, 5657
Career development, 186
Case-study format, 176
CDSS, 257, 258
Chief customer ofcer, 15
Classroom training, 17576
Cleanliness, 96
Clinical decision support system. See CDSS
Clinical/task competency, 151
Clinician: interaction, 89; service delivery
system component, 43
Cognitive response, 102
Comment cards, 34446
Commitment, 110
Competencies: areas of, 137; customer service/
communication, 13738;
hidden, 137; staff, 13638
Competency-based benchmarking, 14546
Competition: as recruitment source, 143
Competitive advantage: achievement, 11; culture
as, 114; customer service as, 35
Complaint behavior, 373
Complaints: data utilization, 36768; most
common, 34; welcoming, 3334, 36465
Computer-based training programs, 17879
Concierge medicine, 2122, 9192
Conscientiousness, 14647
Consumer Assessment of Healthcare Provider
and Systems. See CAHPS
432 Index
Consumer: condence of, 5; informing, 240
41; role changes, 21718
Consumer-driven healthcare: market trends,
1617; reform and, 384, 38687
Content mastery testing, 174
Continuous quality improvement. See CQI
Control, 7
Control factors, 23132
Convenience, 78
Coproduction: advantages/disadvantages,
22428, 230; costbenet
analysis, 23233; determinants, 23035;
patient roles, 222; perspective on, 228
29; reasons for, 23132; service excellence
model, 400401
Core competencies: culture and, 114;
denition, 60; internal
assessment, 6061
Costbenet analysis, coproduction, 23233
Cost: evidence-based design, 83; savings, 247;
total healthcare experience, 48
CQI: accreditation criteria, 12
Critical incident: explanation, 46; skills, 151;
survey technique, 35253
Critical path, 288, 289
Critical skills, 168
CRM, 3132
Cross-functional organization, 29395, 296
Cross-functional training, 181
Cues, 71, 73
Cultural competence, 8
Cultural norms, 1078
Culture: basic elements, 10610; changing,
12426; communication of, 11720;
conversions, 12526; denition, 105;
importance of, 11317; leaders role, 110
13; patient-centered, 11213; practicing,
11213; reinforcement, 12123; teaching,
12024; translating, 112
Customer: defection, 36364; denition
of, 4; expectations, 12; focus, 2122;
information, 241; loyalty, 911; types, 13
Customer contact: group, 253; improvement
strategies, 45;
scheduled time for, 124
Customer relationship management. See CRM
Customer service: chain, 2830; expectations,
13; fundamentals, 19; mission statement
and, 64; retreats, 180; Web-based
technology, 242
Customization, 8
Decision making: culture and, 116; facilitating,
25758; Internet and, 24546; process
stages, 20911
Decision modeling, 256
Decision systems, 25556
Delphi technique, 58
Demand management, 3067, 369
Design day, 56, 31011
Distributive fairness, 378
Diversity training, 18182
Econometric models, 55
ED: triage, 3067; wait time, 302
Electronic medical record: breach of, 26263;
Web-based technology, 24142
Emergency department. See ED
Emotional commitment, 14647
Emotional response, 1023
Employee: acknowledgment of, 190;
behavior, 70, 399400; coaching, 196;
contributions of, 13235; desires,
194; development programs, 18487;
empowering, 132, 20714; engagement,
39598; feedback, 33738; general
abilities, 14647; healing environment,
8889; job analysis process, 13538; job
crafting, 14748; mission-focused, 192
94; motivation of, 18994; outputinput
ratio, 19293; performance rewards,
19899; performance standards, 399
400; personorganization t, 14849;
recruitment process, 13844; retention,
15356; rewards/recognition, 39899;
satisfaction, 117, 15354, 19498;
screening methods, 14953; selection,
14449, 39698; service delivery, 43;
service lovers, 13435; shortages, 13334;
survey, 19698; training, 39698; work
teams, 2017
Empowerment: benet, 207; degrees of,
208; electronic recordkeeping, 247;
explanation, 208; job content/context
grid, 20811; organizational limitations,
213; Point B strategy, 21012; potential,
Index 433
21314; program implementation,
21213
Environment: assessment, 52, 59; dimensions
of, 94100; factors, 8182;
sounds, 9596
Evangelist, 364
Evidence-based databases, 25253
Evidence-based design, 8283, 8384
Expectations: awareness of, 12; external
customers; 3035; internal customers,
35; management of, 3233; variability, 33
Experience economy, 24, 4042
Expert systems, 25659
External assessment, 5459
External customer, 3035
External environment, 11415
External training, 17374
15foot rule, 107
Family: role of, 219
Feedback: employee, 33738; service
excellence model, 39394;
training, 17273
Fellowship program, 18687
Financial compensation policies, 200
Finders fee, 141
Fishbone analysis, 28385
Flowchart, 280
Focus group: coproduction strategy, 221;
qualitative assessment, 58, 338;
recruitment, 141
Folkways, 109
Food service: trends, 91
Forecasting, 5459, 369
Formalized learning, 169
Functional congruence, 97
General abilities, 14647
General education, 18586
Globalization, 1718
Green movement, 9293
Guestology, 2627
Guest service representatives, 90
Healing environment: creation approaches,
86; effects of, 83; elements conducive to,
8485; employees and, 8889; family-
friendly designs, 85; humor and, 8788;
nature and, 85, 87
Health advice: Web-based technology, 24142
Healthcare database, 243
Healthcare Effectiveness Data and Information
Set. See HEDIS
Healthcare hours, 151
Healthcare organization, as information
system, 26468
Healthcare support group, 253
Health information systems. See Information
systems
Health insurance: rating service, 15; Web-
based technology, 241
Healthplexes, 9394
Healthscape, 43
HEDIS, 14
Heroes, 11819
High-involvement work environment, 117
Homelike design, 85
Hospital: rating service, 1415
Hotel-style amenities, 9091
Human resources system: organizational
culture and, 123
Humor, 8788
Individual needs assessment, 171
Inducements, 200201
Information: bad, 261; condentiality,
26163; electronic expertise, 25253;
level-to-level ow, 25355; overload,
26061; primacy of, 265; security, 261
63; service delivery system, 351; service
environment, 25051; service product,
24950; on service quality, 25152;
sharing, 247
Information ow: increasing, 26566; intranet
utilization, 26667; reducing need, 266
Information system: advantages/disadvantages,
260; customer-contact group, 253;
decision systems, 25556; expert systems,
25659; healthcare organization as,
26468; healthcare support group,
253; information ow, 25355;
interconnectivity, 26768; learning cost,
264; problems with, 25964; service
delivery, 43; value of, 24041; value
434 Index
versus cost, 26364
Information technology: growth, 24149;
patient access, 243; personalized service,
24849; smart card, 249; Web-based
strategies, 24142
Intangible services, 3839
Integrated systems, 26768
Interaction: behavioral guidelines, 108; caring
approach, 89; matrix, 37
Interactive fairness, 378
Internal assessment, 53, 6062
Internal customer: expectations, 35; metrics,
35051
Internal environment, 11415
Internal training, 17374
Internet: decision-making aid, 24546;
electronic recordkeeping, 247; growing
role of, 24149; pharmacy, 241;
providerconsumer connectivity, 248;
telemedicine, 24647; as tool, 24448
Interview, 14951, 35153
Inventory management services, 250
Job analysis, 13536
Job content/context grid, 20811
Job crafting, 14748
Key drivers, 30, 70, 39092
Knowledge, 168
Knowledge, skills, and abilities. See KSA
KSA, 13536, 145, 218
Laws, 11718
Leader: development, 16062; role of, 406;
service excellence model, 4048
Leadership components, 407
Lecture, 17576
Legends, 11819
Lighting, 96
Loyalty, 911, 8994
Mail surveys, 34647
Management by walking around. See MBWA
Management observation, 33337
Manager: competencies, 61; intervention,
19495; retention role of, 15455;
skills, 199201
Market trends, 1118
MBWA, 333
Medical errors, 263
Medical record, 247
Medical staff. See Staff
Medical status, 41
Medical tourism, 17
Medication errors, 254
Mental abilities, 146
Mentorship program, 18687
Migration, 59
Mission, 52
Mission statement, 63, 6465, 123
Moderators, 100101
Moment of truth, 4446
Monetary cost, 48
Monte Carlo simulation, 31819
Mores, 109
Motivation: of employees, 18994
Music, 9596
Mystery shoppers, 35455
Nature, 85, 87
Needs assessment, 17072
Neighborhooding technique, 85
Noise, 95
Norms, 1078
Nurse: care teams, 204; job crafting, 14748;
shortages, 133; retention, 155
Occupied time, 32324
Ofce visit: owchart of, 280
Ombudsman, 33738
On-the-job training, 17778
Opportunity cost, 48
Orientation, 181
ORYX: measurement data, 1213
Outcome fairness, 378
Outputinput ratio, 19293
Palliative care, 222
Pareto analysis, 283, 285, 286
Patient: collaborator, 2223; consultant, 22021;
control factors, 23132; coproduction, 225
Index 435
28, 230; decision making, 233; denition
of, 4; environment, 22122; expectations,
69; ring of, 23435; involvement strategy,
21924; manager, 22324; motivator, 223;
participation, 7; quasi-employee, 21819;
remote monitoring, 38; satisfaction, 11314,
117; service excellence model, 400401;
service failure role, 362; stakeholder, 5; time
perception, 23132; training, 165, 17273;
voice of, 56
Patientdoctor relationship, 247
Patient-involvement movement, 1617
Peer interview, 150
Perception, 8182
Performance: appraisal, 195, 196;
improvement, 7273, 19596;
measurement, 1215; reporting, 1516;
rewards, 19899; standards, 341, 344,
37071; 399400
Personal control, 6
Personal health record. See PHR
Personal interviews, 35152
Personality: dimensions, 152
Personalized service, 24849
Personorganization t, 14849
PERT/CPM diagram, 28792
Pharmacy: Web-based technology, 241
PHR, 244
Physical environment, 79
Physical production tools, 43
Physician: training feedback, 17273
Physiological response, 1012
Poka-yoke, 37172
Preference card, 6667
Primary care: independent practices, 2122;
provider shortage, 388; service excellence
and, 19; retainer, 9192
Primary customer, 4, 3035
Procedural fairness, 37778
Professional associations, 14142
Professional networking sites, 153
Providerconsumer connectivity, 248
Providers: Web-based technology, 241
Psychological tests, 15152
Public trust, 5
Qualitative assessment: advantages/
disadvantages, 33435; employee
feedback, 33738; focus groups, 338;
management observation, 333, 33637;
service guarantees, 33840;
techniques, 5759, 33340
Quality: cost of, 49; equation, 47;
improvement, 12, 247; total healthcare
experience, 4748; service strategy
factor, 6667; teams, 36970
Quality assessment: public metrics, 35556;
qualitative methods, 33340; quantitative
methods, 34055; technique utilization,
35657
Quantitative assessment: advantages/
disadvantages, 34243; comment cards,
34446; critical incidents, 35253;
internal customer metrics, 35051;
mystery shopper, 35455; performance
standards, 341, 344; personal interviews,
35152; surveys, 34650; techniques,
5557, 34055; telephone interviews,
353; Web-based survey, 353
Quasi-employee, 21819
Queue: discipline, 314; simulation, 31719;
types of, 31417
Queuing theory, 31319
Re-hires, 141
Readmissions, 222
Recordkeeping: electronic, 247
Recruitment: challenges, 134; creative
approaches, 14044; external candidates,
140; internal candidates, 13840; process
evaluation, 144; sources, 14144
Reference checks, 15253
Referrals, 241
Regression analysis, 55
Reimbursement reform, 38889
Reimbursement system, 1920
Report cards, 1314
Reporting, 93
Respect, 6
Retail clinics, 8
Retail model, 21
Retention, 15356
Retraining, 180
Rewards/recognition, 19899, 39899
Risk, 230
Risk cost, 48
436 Index
Rituals, 11920
Roleplaying: sessions, 167; training method,
18081
Rounding, 333, 336
Safeguards, 167
Satisfactionloyaltyoutcomes chain, 29
Scenario building, 5859
Scripts, 12122
Secondary customer, 4
Self-directed work team, 204
Self-inspection, 371, 372
Self-insurance, 17
Self-management, 116
Service delivery system: analysis, 27478;
cross-functional organization, 29395;
design review, 27273; shbone
analysis, 28385; information and, 251;
organizational components, 4346;
Pareto analysis, 283, 285, 286; PERT/
CPM diagram, 28792; planning
techniques, 27893; self-correcting, 273;
simulations, 29293
Service excellence: benchmark organizations,
1819, 20; challenges, 1920;
characteristics, 27; fundamental concepts,
2124; monetary reward, 20
Service excellence model: competition,
39495; consumer-driven healthcare,
384, 38687; culture, 394; feedback,
39394; framework, 385; healthcare
reform, 384,38687; key drivers,
39092; outcome documentation, 387;
patient extras, 39293; planning, 393;
reimbursement reform, 38889; stafng,
395401; strategy, 38995; systems,
4014
Service failure: customer defection, 36364;
customer response, 36466; data,
36768; dollar value, 366; elements of,
36064; patients role, 362; sources, 361
Service product: components, 4243;
information and, 24950;
tangible versus intangible, 3637
Service providers: customer interaction, 3738;
empowerment, 3940
Service quality: capacity design and, 3045;
factors, 159; information on, 25152;
participation and, 23031
Service rate, 320
Service recovery: employee-driven strategies,
37577; impact, 367; outcomes, 363;
outcome strategies, 37475; patient
evaluation, 37778; preventive strategies,
36872; principles, 375; problem
severity, 38081; process strategies,
37273; strategy characteristics, 37881;
suggestions, 376
Service setting: environmental dimensions of,
94100; importance of, 8082; overview,
43; purpose of, 80; trends, 8994
Service strategy: achievement, 67; action plans,
6769; overview, 6566; quality, 6667;
value, 6667
Service time, 314
Servicescape, 43, 100103
SERVQUAL, 34750
Shopping: Web-based technology, 241
Signs, 9899
Simulation, 29293, 36970
Smart card, 249
Social networking, 153, 24344
Social responsibility, 8
Source inspection, 371, 372
Spatial conditions, 9798
Special competencies training, 181
Stakeholders, 45
Statistical forecasting, 55
Strategic planning: alignment audit, 6974;
process, 5254
Structured questions, 151
Students: as recruitment source, 142
Subculture, 10910
Successive inspection, 371, 372
Surveys, 338, 34650, 353
Symbols, 99, 11920
Task needs assessment, 171
Telemedicine: Internet and, 24647; Web
based technology, 24142
Telephone interviews, 353
Themes, 8990
Third-party payer, 45
Time factors, 23132
Time savings, 247
Time series analysis, 55
Index 437
Total healthcare experience: cost, 48; quality
of, 4748; service delivery system, 4346;
service product, 4243; service setting,
43; value of, 4849
Total quality management. See TQM
TQM: goal, 274; lessons learned, 272
Training: attitudinal, 18182; barriers, 166;
benets, 163, 166, 184; classroom
presentation, 17576;
components, 162; computer-based
learning, 17879; cost analysis, 184;
cross-functional, 181; customer service
retreats, 180; diversity, 18182; external
versus internal, 17374; feedback,
17273; frontline staff, 163; job
instruction technique, 178; leaders,
16062; measurements, 17475,
18384; methods, 17583; objective,
172, 183; on-the-job supervision,
17778; orientation, 181; patients, 165;
problems/pitfalls, 18384; retention
impact, 16466; roleplaying method,
18081; service excellence model,
39698; service recovery strategy,
36970; special competencies, 181; staff,
16266; turnover impact, 16466; video
instruction, 17677
Training program: big picture reinforcement,
16869; components, 17075;
continuous improvement, 170;
development guidelines, 16768;
formalized learning, 169; multiple
learning approaches, 170
Transactional administrators, 191
Transactional leaders, 111
Transactional skill, 199
Transformational leaders, 11112, 191
Transformational leadership skill, 200
Trend analysis, 55
Triage, 3067
Tuition reimbursement policy, 185
University collaboration, 141
Value: congruence, 148; differential, 11;
equation, 48; of total healthcare
experience, 4849; perceived, 9; service
strategy factor, 6667;
Values: customer-focused, 1067; examples of,
52; cultural reinforcement, 11516
Video training, 17677
Virtual wait strategy, 308
Vision, 52
Vision statement, 6264, 123
Wait management: perceived service value,
32728; perceptions, 32328; practices,
322
Wait time: for appointment, 303; capacity
decision, 30412; denition, 300;
diversions, 3078; ED, 302; importance
of, 300303; management, 31223;
organizational options, 30512; patient
dissatisfaction with, 3012; physician,
3023; queuing theory, 31319; service
time versus, 324; solo versus group, 326;
standards, 30910; tracking, 310;
for treatment, 303; uncertain lengths,
325; uncomfortable waits, 326;
unexplained waits, 325; unfair, 32526;
uninteresting, 326; virtual strategy, 308;
capacitydemand balance, 319, 32123;
service excellence model, 402
Waiting area: hotel-style amenities, 9091;
improvements, 3089
War gaming, 5859
Web-based survey, 353
Word of mouth, 36566
Work team: benets of, 2014; characteristics,
202; nursing care, 204; problems, 2045;
self-directed, 204; utilization, 2067
Yield management, 57
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439
About the Authors
Myron D. Fottler, PhD, is a professor and executive director of the Health Services
Administration Programs in the College of Health and Public Affairs at the University of
Central Florida, where he teaches courses in healthcare human resources management,
service management and marketing, and dissertation research. His research interests
include all aspects of human resources management, service management, stakeholder
management, strategic management, integrated delivery systems, and healthcare
report cards. He has won awards from the American College of Healthcare Executives,
American Association of Medical Administrators, and the Healthcare Management
Division of the Academy of Management for his research. His publications include 18
books and more than 100 journal articles.
Previously, Dr. Fottler was professor and director of the PhD program in
AdministrationHealth Services, with a joint appointment in both the School of
Health Related Professions and the School of Business at the University of Alabama at
Birmingham. He completed his MBA at Boston University and his PhD in business
at Columbia University. He has been active in both the Academy of Management
and the Association of University Programs in Health Administration. He has also
served on several editorial review boards and is a founding coeditor of Advances in
Health Care Management, an annual research volume published by JAI/Elsevier.
Dr. Fottler has served as a member of the editorial boards for Medical Care Research
and Review, International Journal of Applied Quality Management, Journal of Health
Administration Education and Health Care Management Review. He has served as a
reviewer for Industrial and Labor Relations Review, Industrial Relations, Academy of
Management Review, Medical Care, Journal of Management, Journal of Occupational
Behavior, Health Services Research, Hospital & Health Services Administration, Health Care
Financing Review, Journal of Management Studies, Journal of Healthcare Management,
Journal of Labor Studies, and Academy of Management Journal. He has been listed in
numerous biographical publications, including Dictionary of International Biography,
Whos Who in The World, Outstanding Young Men in America, Whos Who in the East,
Contemporary Authors, International Directory of Business and Management Scholars
and Research, American Men and Women of Science, International Writers and Authors
Whos Who, and Directory of American Scholars.
440 About the Authors
Robert C. Ford, PhD, is a professor of management in the College of Business
Administration at the University of Central Florida (UCF). He joined UCF in 1993
as chair of the Department of Hospitality Management, and, until 2003, he was
associate dean for Graduate and External Programs. He also served on the management
faculty of the University of North Florida and was management department chair
and a member of the faculty at the University of Alabama at Birmingham.
Dr. Ford has authored or coauthored more than 100 articles, books, and
presentations on organizational issues, human resources management, and services
management, especially as it relates to healthcare and hospitality applications.
He won the 2001 Sodexho Marriott Health Care Division Faculty Publication
of the Year for a coauthored article with Myron Fottler. He has published in a
wide variety of academic and practitioner journals, including the Journal of Applied
Psychology, Academy of Management Journal, Organizational Dynamics, Health Care
Management Review, and The Academy of Management Executive. His books include
Principles of Management, Organization Theory, Managing the Guest Experience
in Hospitality, Achieving Service Excellence, Leading with a Laugh, and Managing
Destination Marketing Organizations.
Dr. Ford was editor of the Academy of Management Executive and chair of both
Management History and Management Education and Management Development
Divisions of the Academy of Management. In addition, he has been the chair of
the Accreditation Commission for Programs in Hospitality Administration. He is
a Fellow and former dean of the Southern Management Association.
Cherrill P. Heaton, PhD, was a professor of organizational communications at the
University of North Florida. In addition to teaching organizational and business
communications in the MBA and M.Acc. programs, he taught more than 100 short
courses for business and industry in these areas. He was editor of Management by Objectives
in Higher Education and was coauthor of Essentials of Modern Investments and several
articles and three books (with Robert Ford): Principles of Management, Organization
Theory, and Managing the Guest Experience in Hospitality. In addition, Dr. Heaton was
managing editor of the Academy of Management Executive. He is now retired.